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Background: Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%). Methods: From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes. Results: Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA (n = 6), middle cerebral artery (n = 10), basilar artery (n = 3), intracranial vertebral artery (n = 3), and the vertebrobasilar junction (n = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%). Conclusion: Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment. [ABSTRACT FROM AUTHOR]

Background: Pulsatile tinnitus (PT) is a rare form of tinnitus that aligns with the heartbeat. It is typically brought on by lesions with significant vascularity, which produce aberrant sound conduction and increase the risk of mental health issues and hearing loss. Venous PT is more prevalent than arterial PT. Open procedures or interventional procedures can be used to treat PT. We present here a case of PT caused by venous luminal stenosis combined with jugular bulb (JB) malformation, which was improved by stenting and JB embolization. Case presentation: A 59-year-old woman presented with long-term tinnitus consistent with heart rhythm and hearing loss, accompanied by anxiety, insomnia, and depression. The results of brainMRV, CT, and DSA showed stenosis of the right sigmoid sinus and high jugular bulb (JB) with dehiscence of the JB wall. The patient saw a significant improvement in PT symptoms following sigmoid sinus stenting and spring coil embolization of the high JB, following the diagnosis of PT. The patient had no PT recurrence for the course of the 31-month follow-up period. Conclusion: In the present PT case, there was a simultaneous onset of the right sigmoid sinus stenosis and the high JB with the JB wall abnormalities. Sigmoid sinus stenting and spring coil embolization of high JBmay be a treatment for the PT, but the prevention of post-stenting complications is still an issue that requires great attention and needs further study. [ABSTRACT FROM AUTHOR]

Background: White cord syndrome is an uncommon complication characterized by delayed neurologic deterioration with no other identified cause after spinal decompression surgery. Its etiology is attributed to spinal cord reperfusion injury. Here, we present the first case of an extended version of white cord syndrome, with concomitant involvement of the medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting. Case presentation: A 56-year-old male suffered an ischemic stroke in the right anteromedial medulla oblongata. Angiography revealed bilateral vertebral artery stenosis in the intracranial segment. We performed elective left vertebral artery angioplasty and stenting. An intraoperative flow arrest in the left VA occurred and was stopped after the withdrawal of the catheter. Several hours after the operation, the patient developed occipital headache, back neck pain, dysarthria, and worsening left-sided hemiplegia. Magnetic resonance imaging revealed hyperintensity and swelling in the medulla oblongata and cervical cord, in addition to small medullary infarction. A digital subtraction angiography revealed intact vertebrobasilar arteries and patency of the left vertebral artery, left posterior inferior cerebellar artery, and implanted stent. We considered that the reperfusion injury had caused the complication. After treatment, the patient's symptoms and neurologic deficits greatly improved. He achieved a favorable outcome at the 1-year follow-up, with normal intensity restored in the medulla oblongata and cervical cord on magnetic resonance imaging. Conclusion: Concomitant reperfusion injury in the medulla oblongata and cervical cord secondary to vertebral artery angioplasty and stenting is extremely rare. However, this potentially devastating complication requires early recognition and prompt treatment. Maintaining the antegrade flow during vertebral artery endovascular treatment is a precaution against reperfusion injury. [ABSTRACT FROM AUTHOR]

Extracranial carotid artery aneurysms (ECAA) and carotid-cavernous fistulas (CCF) are rare arterial pathologies with severe complications and increased risk of mortality. The optimal treatment approach for this combined condition is a topic of debate among neurosurgeons and neuroradiologists, and a standardized treatment protocol has yet to be established. The aim of this case report was to demonstrate the management of a rare combination of ECAA and CCF in patients. The treatment strategy included a two-step procedure of endovascular embolization of CCF followed by dual antiplatelet therapy and endovascular stenting of an aneurysm. Control angiograms showed the exclusion of an aneurysm from the blood circulation and CCF symptoms were resolved. [ABSTRACT FROM AUTHOR]

Extracranial carotid artery aneurysms (ECAA) and carotid-cavernous fistulas (CCF) are rare arterial pathologies with severe complications and increased risk of mortality. The optimal treatment approach for this combined condition is a topic of debate among neurosurgeons and neuroradiologists, and a standardized treatment protocol has yet to be established. The aim of this case report was to demonstrate the management of a rare combination of ECAA and CCF in patients. The treatment strategy included a two-step procedure of endovascular embolization of CCF followed by dual antiplatelet therapy and endovascular stenting of an aneurysm. Control angiograms showed the exclusion of an aneurysm from the blood circulation and CCF symptoms were resolved.

Aims: We performed a meta-analysis to indirectly compare the treatment effectiveness of balloon angioplasty and stenting for patients with intracranial arterial stenosis. Methods: Literature searches were performed in well-known databases to identify eligible studies published before January 04, 2021. The incidence of restenosis, transient ischemic attack (TIA), stroke, death, and dissection after balloon angioplasty or stenting were pooled. An indirect comparison of balloon angioplasty vs. stenting was performed, and the ratios of incidence (RIs) with 95% confidence intervals (CIs) were calculated using the random-effects model. Results: 120 studies that recruited 10,107 patients with intracranial arterial stenosis were included. The pooled incidence of restenosis after balloon angioplasty and stenting were 13% (95%CI: 8-17%) and 11% (95%CI: 9-13%), respectively, with no significant difference between them (RI: 1.18; 95%CI: 0.78–1.80; P = 0.435). Moreover, the pooled incidence of TIA after balloon angioplasty and stenting was 3% (95%CI: 0–6%) and 4% (95%CI: 3%-5%), and no significant difference was observed (RI: 0.75; 95%CI: 0.01–58.53; P = 0.897). The pooled incidence of stroke after balloon angioplasty and stenting was 7% (95%CI: 5–9%) and 8% (95%CI: 7–9%), respectively, and the difference between groups was found to be statistically insignificant (RI: 0.88; 95%CI: 0.64–1.20; P = 0.413). Additionally, the pooled incidence of death after balloon angioplasty and stenting was 2% (95%CI: 1–4%) and 2% (95%CI: 1–2%), with no significant difference between groups (RI: 1.00; 95%CI: 0.44–2.27; P = 1.000). Finally, the pooled incidence of dissection after balloon angioplasty and stenting was 13% (95%CI: 5–22%) and 3% (95%CI: 2–5%), respectively, and balloon angioplasty was associated with a higher risk of dissection than that with stenting for patients with intracranial arterial stenosis (RI: 4.33; 95%CI: 1.81–10.35; P = 0.001). Conclusion: This study found that the treatment effectiveness of balloon angioplasty and stenting were similar for patients with symptomatic intracranial arterial stenosis. [ABSTRACT FROM AUTHOR]

AimsWe performed a meta-analysis to indirectly compare the treatment effectiveness of balloon angioplasty and stenting for patients with intracranial arterial stenosis.MethodsLiterature searches were performed in well-known databases to identify eligible studies published before January 04, 2021. The incidence of restenosis, transient ischemic attack (TIA), stroke, death, and dissection after balloon angioplasty or stenting were pooled. An indirect comparison of balloon angioplasty vs. stenting was performed, and the ratios of incidence (RIs) with 95% confidence intervals (CIs) were calculated using the random-effects model.Results120 studies that recruited 10,107 patients with intracranial arterial stenosis were included. The pooled incidence of restenosis after balloon angioplasty and stenting were 13% (95%CI: 8-17%) and 11% (95%CI: 9-13%), respectively, with no significant difference between them (RI: 1.18; 95%CI: 0.78–1.80; P = 0.435). Moreover, the pooled incidence of TIA after balloon angioplasty and stenting was 3% (95%CI: 0–6%) and 4% (95%CI: 3%-5%), and no significant difference was observed (RI: 0.75; 95%CI: 0.01–58.53; P = 0.897). The pooled incidence of stroke after balloon angioplasty and stenting was 7% (95%CI: 5–9%) and 8% (95%CI: 7–9%), respectively, and the difference between groups was found to be statistically insignificant (RI: 0.88; 95%CI: 0.64–1.20; P = 0.413). Additionally, the pooled incidence of death after balloon angioplasty and stenting was 2% (95%CI: 1–4%) and 2% (95%CI: 1–2%), with no significant difference between groups (RI: 1.00; 95%CI: 0.44–2.27; P = 1.000). Finally, the pooled incidence of dissection after balloon angioplasty and stenting was 13% (95%CI: 5–22%) and 3% (95%CI: 2–5%), respectively, and balloon angioplasty was associated with a higher risk of dissection than that with stenting for patients with intracranial arterial stenosis (RI: 4.33; 95%CI: 1.81–10.35; P = 0.001).ConclusionThis study found that the treatment effectiveness of balloon angioplasty and stenting were similar for patients with symptomatic intracranial arterial stenosis.

Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with high risk of stroke recurrence. While the most common clinical presentation is acute–subacute transient ischemic attack or ischemic stroke, occasionally, patients with underlying ICAS present with acute occlusion of the affected vessel. Diagnosis and endovascular management of ICAS-related emergent large vessel occlusion (ELVO) can be challenging. Herein, we review the current evidence supporting endovascular management of ICAS-related ELVO and discuss future directions. [ABSTRACT FROM AUTHOR]

Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with high risk of stroke recurrence. While the most common clinical presentation is acute–subacute transient ischemic attack or ischemic stroke, occasionally, patients with underlying ICAS present with acute occlusion of the affected vessel. Diagnosis and endovascular management of ICAS-related emergent large vessel occlusion (ELVO) can be challenging. Herein, we review the current evidence supporting endovascular management of ICAS-related ELVO and discuss future directions.

Few studies have reported on simultaneous endovascular stenting for tandem posterior circulation (PC) stenoses and its long-term outcomes. Thus, our aim was to investigate the safety and efficacy of simultaneous stenting in patients with symptomatic tandem extra- and intracranial PC stenoses. From September 2014 to June 2018, 16 such patients with symptomatic stenoses who underwent simultaneous stent placement were analyzed. The primary outcome was occurrence of any stroke, TIA, or death within 30 days after the procedure. The secondary outcomes were technical success, clinical success, and the occurrence of in-stent restenosis ≥50% during follow-up. Technical success was defined as stent coverage of all tandem lesions and residual stenosis

Few studies have reported on simultaneous endovascular stenting for tandem posterior circulation (PC) stenoses and its long-term outcomes. Thus, our aim was to investigate the safety and efficacy of simultaneous stenting in patients with symptomatic tandem extra- and intracranial PC stenoses. From September 2014 to June 2018, 16 such patients with symptomatic stenoses who underwent simultaneous stent placement were analyzed. The primary outcome was occurrence of any stroke, TIA, or death within 30 days after the procedure. The secondary outcomes were technical success, clinical success, and the occurrence of in-stent restenosis ≥50% during follow-up. Technical success was defined as stent coverage of all tandem lesions and residual stenosis <30%. Clinical success was determined based on any occurrence of neurological events or death within 3 months after the procedure. All stents (19 intracranial and 14 extracranial) were placed with a technical success rate of 100%. One patient experienced a pontine ischemic stroke 2 days after the procedure and had recovered well at discharge. One patient experienced a minor complication of groin hematoma. The clinical success rate was 93.75% (15/16). During a median follow-up of 36.0 ± 11.0 months, two patients developed ISR ≥50% at the 1-year follow-up. None of the patients experienced stroke, TIA, or death after discharge during follow-up. Simultaneous stenting for symptomatic tandem extra- and intracranial PC stenoses is safe and feasible. Its impact on long-term stroke prevention is promising, and further study of a larger patient population is needed. [ABSTRACT FROM AUTHOR]

Objective: We described the incidence of surgery-related complications to evaluate the safety of endovascular therapy for severe symptomatic intracranial vertebral basilar artery stenosis (IVBS) in our stroke center in Northeast of China.Methods: Consecutive patients with symptomatic IVBS caused by 70–99% stenosis despite standard medical treatment of antiplatelet agents plus statin were enrolled. Either balloon-mounted stent or balloon predilation plus self-expanding stent was performed. Clinical adverse events such as stroke, transient ischemic attack (TIA), and death after the surgery were documented. Radiological events such as in-stent thrombosis, dissection, and guide-wire perforation during the process were recorded as complications as well. The baseline characteristics and outcomes of patients among different Mori types were compared.Results: From January 2017 to December 2018, 97 patients with stroke or TIA due to intracranial IVBS were treated by stenting, including 30 patients with basilar artery (BA) stenosis, 55 patients with intracranial vertebral artery (V4) stenosis, and 12 patients with V4-BA stenosis. The primary events include two intracranial hemorrhage (2.1%, 2/97), seven ischemic events (7.2%, 7/97), and two death (2.1%, 2/97). The successful stent deployment rate was 98.9% (96/97). The Apollo stents were used more for Mori A lesions. Self-expanding stents were more used in Mori C lesions. Mori C lesions were more vulnerable to endovascular procedure and showed higher rate of complications than A (p = 0.008) and B type (p = 0.047).Conclusion: A high technical success rate of IVBS stenting could be achieved, and the safety was acceptable, whereas Mori C lesions were more vulnerable to endovascular procedure and showed a higher rate of complications than A and B types.

Objective: We described the incidence of surgery-related complications to evaluate the safety of endovascular therapy for severe symptomatic intracranial vertebral basilar artery stenosis (IVBS) in our stroke center in Northeast of China. Methods: Consecutive patients with symptomatic IVBS caused by 70–99% stenosis despite standard medical treatment of antiplatelet agents plus statin were enrolled. Either balloon-mounted stent or balloon predilation plus self-expanding stent was performed. Clinical adverse events such as stroke, transient ischemic attack (TIA), and death after the surgery were documented. Radiological events such as in-stent thrombosis, dissection, and guide-wire perforation during the process were recorded as complications as well. The baseline characteristics and outcomes of patients among different Mori types were compared. Results: From January 2017 to December 2018, 97 patients with stroke or TIA due to intracranial IVBS were treated by stenting, including 30 patients with basilar artery (BA) stenosis, 55 patients with intracranial vertebral artery (V4) stenosis, and 12 patients with V4-BA stenosis. The primary events include two intracranial hemorrhage (2.1%, 2/97), seven ischemic events (7.2%, 7/97), and two death (2.1%, 2/97). The successful stent deployment rate was 98.9% (96/97). The Apollo stents were used more for Mori A lesions. Self-expanding stents were more used in Mori C lesions. Mori C lesions were more vulnerable to endovascular procedure and showed higher rate of complications than A (p = 0.008) and B type (p = 0.047). Conclusion: A high technical success rate of IVBS stenting could be achieved, and the safety was acceptable, whereas Mori C lesions were more vulnerable to endovascular procedure and showed a higher rate of complications than A and B types. [ABSTRACT FROM AUTHOR]

Background and Purpose: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke worldwide. Although there are different endovascular options for the treatment of symptomatic ICAD (sICAD), it is still controversial. Herein, we aim to study the safety and efficacy of a new generation of drug-eluting balloon-mounted stent (DES); Resolute (R) onyx DES in the treatment of sICAD.Methods: A prospectively maintained neuroendovascular procedures database in a high-volume comprehensive stroke center was reviewed from October 2019 through January 2020. Patients were included if they had sICAD (≥70% stenosis), failed medical management, and underwent intracranial stenting with R-onyx DES. Technical success was defined as the ability to deploy the device at the desired location and achievement of

Background and Purpose: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke worldwide. Although there are different endovascular options for the treatment of symptomatic ICAD (sICAD), it is still controversial. Herein, we aim to study the safety and efficacy of a new generation of drug-eluting balloon-mounted stent (DES); Resolute (R) onyx DES in the treatment of sICAD. Methods: A prospectively maintained neuroendovascular procedures database in a high-volume comprehensive stroke center was reviewed from October 2019 through January 2020. Patients were included if they had sICAD (≥70% stenosis), failed medical management, and underwent intracranial stenting with R-onyx DES. Technical success was defined as the ability to deploy the device at the desired location and achievement of <30% residual stenosis. The primary outcome was the occurrence of complications within 72 h of the procedure (strokes, ischemic or hemorrhagic; and mortality). Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure. Results: A total of 18 consecutive patients (mean age, 66.6 years; 44.4% were females and 94.4% were Hispanic) were eligible for the analysis. Indication for treatment was recurrent strokes in 13 and recurrent transient ischemic attack (TIA) in 5. A total of 22 symptomatic lesions with a mean baseline stenosis percent (84.9 ± 9.6) were treated using 23 R-onyx DES in 19 procedures. All procedures were done under general anesthesia with 100% technical success, and no reported periprocedural strokes or death. Among 13 patients who had clinical follow-up, 1 (7.7%) patient had TIA. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for 9 (50%) patients showed no in-stent restenosis. Conclusion: The use of R-onyx DES in the treatment of sICAD is safe with high technical success rates. Large prospective multicenter trials with long-term follow-up are warranted. [ABSTRACT FROM AUTHOR]

In a multicenter registry study, Guo et al. reported a 8.2% 1-year risk of stroke and vascular death, in patients with symptomatic, high-grade ICAD with imaging evidence of downstream hypoperfusion who received stenting treatment. These two studies have stressed the need to understand the pathophysiology in ICAD-related stroke and to treat ICAD and the stroke mechanism(s) rather than a single stenosis. Keywords: stroke; intracranial atherosclerotic disease; imaging; endovascular treatment; stenting EN stroke intracranial atherosclerotic disease imaging endovascular treatment stenting 1 3 3 10/26/21 20211022 NES 211022 Intracranial atherosclerotic disease (ICAD) is an important cause of ischemic stroke and transient ischemic attack (TIA) worldwide ([1]). [Extracted from the article]

Objective: To report a single-center experience using drug-eluting balloon mounted stents (DES) for endovascular treatment of atherosclerotic ostial vertebral artery stenosis (OVAS).Background: Posterior circulation is affected in up to 25% of strokes, 20% of them resulting from atherosclerotic OVAS. The optimal management of symptomatic OVAS remains controversial. DES have been introduced to improve restenosis rates.Methods: We retrospectively analyzed prospectively collected data from patients with dominant OVAS who underwent endovascular treatment with second-generation DES placement. Patient demographics, clinical presentation, comorbidities, stenosis severity, stent features, technical success, complications, and imaging follow-up were assessed.Results: Thirty patients were treated, predominantly male (86.6%). Sixteen patients presented with an acute stroke or TIA and fourteen were treated on an elective basis due to symptomatic chronic stenosis and contralateral occlusion. Comorbidities included hyperlipidemia (83%), hypertension (70%) and prior stroke (63.3%). Mean ostial stenosis at presentation was 80 ± 14.8%. Twenty-one patients had contralateral VA involvement. DES deployment was technically successful in all patients using everolimus eluting stents in 30 lesions and zotarolimus eluting stents in two. One technical complication (stent migration) and three (10%) minor peri-procedural complications occurred. Complications included one asymptomatic ischemic infarct in the posterior circulation, one femoral artery thrombosis and one post-procedure altered mental status secondary to contrast induced neurotoxicity. Mean imaging follow-up was 8.8 months. Two (7.6%) patients had in-stent restenosis and underwent retreatment with angioplasty. There were no procedure-related mortalities.Conclusion: Our study confirms the feasibility of deploying DES for the treatment of ostial vertebral artery stenosis with low peri-procedural risk and low medium-term rates of re-stenosis.

Background: Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%)., Methods: From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes., Results: Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA ( n  = 6), middle cerebral artery ( n  = 10), basilar artery ( n  = 3), intracranial vertebral artery ( n  = 3), and the vertebrobasilar junction ( n  = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%)., Conclusion: Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ma, Wang, Feng, Yan, Xu, Cheng and Fang.)

Background and Purpose: Endovascular treatment of tandem occlusions is an emerging option. We describe our multicenter experience with endovascular management of atherosclerotic tandem occlusions in the anterior circulation, particularly the technical aspects and complications in comparison to isolated intracranial occlusions.Materials and Methods: Consecutive patients with tandem occlusions due to atherosclerotic causes who underwent mechanical thrombectomy at two major stroke centers between January 2010 and September 2015 were reviewed. Clinical data, procedural aspects, recanalization rates, complication rates, and clinical outcome were analyzed and compared to findings in patients with isolated intracranial occlusions.Results: One hundred and twenty-one patients with tandem occlusions and 456 patients with isolated intracranial occlusions (carotid-T/M1) were included. Mean intervention time was faster (33 min vs. 57 min, p < 0.001) and recanalization success was higher (TICI 2b/3 83.6 vs. 70.2%, p = 0.002) in patients with isolated occlusions. No difference was seen in clinical outcome and complications, except for a higher rate of asymptomatic hemorrhage in the tandem group (29.8 vs. 17.1%, p = 0.003). Choice of recanalization approach (antegrade vs. retrograde) in the tandem group made no difference, except for a trend toward less distal emboli using the retrograde approach (4.0 vs. 13.0%, p = 0.082). Stenting of the extracranial internal carotid artery (ICA) was performed in 81%, PTA alone in 7.4%, and deferred stenting in 11.6%. Rate of stent/ICA occlusion within 7 days was 10.3% after stenting and 33.3% after PTA (p = 0.127). In the tandem group, age (p = 0.034), National Institutes of Health Stroke Scale score (NIHSS) at admission (p = 0.002), recanalization rate (p < 0.001), complications (p = 0.016), and symptomatic intracranial hemorrhage (sICH) (p = 0.001) were associated with poor outcome, whereas extracranial treatment modality and stent/ICA occlusion within 7 days did not affect outcome.Conclusion: Endovascular treatment of tandem occlusions is technically feasible, achieves recanalization rates and rates of good clinical outcome comparable to those in patients with isolated intracranial occlusions. Following acute ICA stenting, the risk of stent occlusion and sICH appeared to be low, but was associated with an increased rate of asymptomatic ICH.

Objective: To report a single-center experience using drug-eluting balloon mounted stents (DES) for endovascular treatment of atherosclerotic ostial vertebral artery stenosis (OVAS). Background: Posterior circulation is affected in up to 25% of strokes, 20% of them resulting from atherosclerotic OVAS. The optimal management of symptomatic OVAS remains controversial. DES have been introduced to improve restenosis rates. Methods: We retrospectively analyzed prospectively collected data from patients with dominant OVAS who underwent endovascular treatment with second-generation DES placement. Patient demographics, clinical presentation, comorbidities, stenosis severity, stent features, technical success, complications, and imaging follow-up were assessed. Results: Thirty patients were treated, predominantly male (86.6%). Sixteen patients presented with an acute stroke or TIA and fourteen were treated on an elective basis due to symptomatic chronic stenosis and contralateral occlusion. Comorbidities included hyperlipidemia (83%), hypertension (70%) and prior stroke (63.3%). Mean ostial stenosis at presentation was 80 ± 14.8%. Twenty-one patients had contralateral VA involvement. DES deployment was technically successful in all patients using everolimus eluting stents in 30 lesions and zotarolimus eluting stents in two. One technical complication (stent migration) and three (10%) minor peri-procedural complications occurred. Complications included one asymptomatic ischemic infarct in the posterior circulation, one femoral artery thrombosis and one post-procedure altered mental status secondary to contrast induced neurotoxicity. Mean imaging follow-up was 8.8 months. Two (7.6%) patients had in-stent restenosis and underwent retreatment with angioplasty. There were no procedure-related mortalities. Conclusion: Our study confirms the feasibility of deploying DES for the treatment of ostial vertebral artery stenosis with low peri-procedural risk and low medium-term rates of re-stenosis. [ABSTRACT FROM AUTHOR]

Background and Purpose: Subgroup analysis of the SAMMPRIS trial showed a higher rate of periprocedural perforator strokes with the Wingspan stent in the basilar artery in patients with symptomatic intracranial atherosclerotic stenosis (ICAS). It remains unclear whether angioplasty (PTA) alone or in combination with other stent types (PTAS) will yield similar results in perforator-bearing segments of the anterior and posterior circulation.Methods: We retrospectively analyzed the periprocedural complication rate, long term outcome and stroke etiology in 59 consecutive patients with ICAS of the middle cerebral artery (79 treatments) and 67 patients with ICAS of the intracranial vertebral and basilar artery (76 treatments) treated with PTA or PTAS from 2007 to 2015 in a high-volume neuro-interventional center.Results: Periprocedural symptomatic ischemic strokes occurred significantly more often in patients with posterior vs. anterior ICAS treatment (14.5 vs. 5.1%, p = 0.048). During a mean follow-up period of 19 (±23.7) months, 5 recurrent ischemic and 2 hemorrhagic strokes (10.4%) occurred in the territory of the treated artery in posterior circulation compared to 2 ischemic strokes in the anterior circulation (3.4%, p = 0.549). Overall, significantly more patients treated for a posterior ICAS suffered a periprocedural or follow-up stroke [25% vs. 11.4%, p = 0.024]. Periprocedural ischemic strokes were predominantly perforator strokes (73.3%), while all ischemic strokes during follow-up were caused by distal embolization (57.1%) or delayed stent occlusion (42.9%). There was no difference between PTA alone and PTAS.Conclusion: The periprocedural and long-term symptomatic stroke rate was significantly higher in the treatment of perforator-bearing arteries in the posterior circulation. There was no difference between PTA alone or PTAS.

Background and Purpose: Subgroup analysis of the SAMMPRIS trial showed a higher rate of periprocedural perforator strokes with the Wingspan stent in the basilar artery in patients with symptomatic intracranial atherosclerotic stenosis (ICAS). It remains unclear whether angioplasty (PTA) alone or in combination with other stent types (PTAS) will yield similar results in perforator-bearing segments of the anterior and posterior circulation. Methods: We retrospectively analyzed the periprocedural complication rate, long term outcome and stroke etiology in 59 consecutive patients with ICAS of the middle cerebral artery (79 treatments) and 67 patients with ICAS of the intracranial vertebral and basilar artery (76 treatments) treated with PTA or PTAS from 2007 to 2015 in a high-volume neuro-interventional center. Results: Periprocedural symptomatic ischemic strokes occurred significantly more often in patients with posterior vs. anterior ICAS treatment (14.5 vs. 5.1%, p = 0.048). During a mean follow-up period of 19 (±23.7) months, 5 recurrent ischemic and 2 hemorrhagic strokes (10.4%) occurred in the territory of the treated artery in posterior circulation compared to 2 ischemic strokes in the anterior circulation (3.4%, p = 0.549). Overall, significantly more patients treated for a posterior ICAS suffered a periprocedural or follow-up stroke [25% vs. 11.4%, p = 0.024]. Periprocedural ischemic strokes were predominantly perforator strokes (73.3%), while all ischemic strokes during follow-up were caused by distal embolization (57.1%) or delayed stent occlusion (42.9%). There was no difference between PTA alone and PTAS. Conclusion: The periprocedural and long-term symptomatic stroke rate was significantly higher in the treatment of perforator-bearing arteries in the posterior circulation. There was no difference between PTA alone or PTAS. [ABSTRACT FROM AUTHOR]

Background: Flow diversion (FD)-a young technique using stents with highly increased surface coverage-was introduced to treat complex aneurysms without intra-aneurysmal material placement and has amended the spectrum of endovascular techniques such as stent-assisted coil occlusion considerably. However, ischemic complications, a common side effect in FD, occur more frequently compared with the conventional endovascular approaches and certainly limit the indication of this technique. Our study aimed to investigate the feasibility and efficacy of stent-assisted coiling using low profile self-expandable stents, which exhibit only moderate flow-redirecting properties and therefore represent a combination of hemodynamic endovascular and occlusive endosaccular therapy. Materials and methods: 39 Patients were included in our retrospective study. Occlusion rates were assessed 6 months after the procedure in a total of 27 cases using the Raymond scale. results: Complete occlusion (Raymond I) was achieved in 24/27 aneurysms. Small neck remnants (Raymond II) were evident in 3/27 aneurysms. There were no cases with sac remnant or complete persistence of aneurysmal filling (Raymond III and IV). conclusion: Our study demonstrates interventional treatment of intracranial aneurysms using flow-redirecting stent-assisted coiling to be technically feasible and highly effective in aneurysmal occlusion. We believe that this approach is outstanding in the prevention of long-term aneurysmal reperfusion and exhibits a more acceptable risk profile than highly efficient FD techniques. [ABSTRACT FROM AUTHOR]

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 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.

Intracranial atherosclerotic disease (ICAD) accounts for 33% to 50% of all ischemic strokes in the Asian population [1] and represents an important public health issue in China. The results of the SAMMPRIS trial alarmed most experienced interventionalists in China for two reasons. Firstly, the high complication rate in the stenting arm (20% the first year) was higher than expected. Secondly, the recurrent stroke rate in the aggressive medical treatment (AMT) arm at 12.2% during the first year was unacceptably high, not to mention the fact that such tight vascular risk factor control is difficult to achieve for many patients from real life clinical experience, at least in China. The experience of treating ICAD in China, gained over the last two decades, is very rich and promising. We intend to highlight these past experiences and address future trials and trends in China. We will also address our criticism of the SAMMPRIS trial design in order to better design a future trial.

We review the methods and results of SAMMPRIS and provide a critical review of its strengths and limitations. In SAMMPRIS, the aggressive medical treatment arm (AMT arm) did substantially better than the Wingspan Stenting plus aggressive medical management arm (WS+ arm). Complications in the first 30 days post intervention led to the disparity between treatment arms. A major contribution of SAMMPRIS was the added value that AMT and lifestyle change may provide, when compared to a precursor trial, WASID, designed to prevent stroke in persons with high-grade symptomatic intracranial occlusive disease, however, the results of neither of these two trials has ever been reproduced. On the other hand we argue that technical limitations of the Wingspan stent system (WS System) and lack of an angioplasty only intervention arm may have led to a premature launch of the trial and early termination of the study. Future randomized trials with different devices and modified patient selection criteria are warranted.

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 howto avoid them and how to manage them. Our most recent results (since previous publications) are also discussed. [ABSTRACT FROM AUTHOR]

We review the methods and results of Stenting and Aggressive Medical Management for Preventing Recurrent Stroke (SAMMPRIS) and provide a critical review of its strengths and limitations. In SAMMPRIS, the aggressive medical treatment arm (AMT arm) did substantially better than the Wingspan Stenting plus aggressive medical management arm (WSC arm). Complications in the first 30 days post intervention led to the disparity between treatment arms. A major contribution of SAMMPRIS was the added value that AMT and lifestyle change may provide, when compared to a precursor trial,Warfarin-Aspirin Symptomatic Intracranial Disease (WASID), designed to prevent stroke in persons with high-grade symptomatic intracranial occlusive disease, however, the results of neither of these two trials have ever been reproduced. On the other hand, we argue that technical limitations of the Wingspan stent system (WS System) and lack of an angioplasty only intervention arm may have led to a premature launch of the trial and early termination of the study. Future randomized trials with different devices and modified patient selection criteria are warranted. [ABSTRACT FROM AUTHOR]

Recanalization of acute large artery occlusions is a strong predictor of good outcome. The development of thrombectomy devices resulted in a significant improvement in recanalization rates compared to thrombolytics alone. However, clinical trials and registries with these thrombectomy devices in acute ischemic stroke (AIS) have shown recanalization rates in the range of 40-81%. The last decade has seen the development of nickel titanium self-expandable stents (SES). These stents, in contrast to balloon-mounted stents, allow better navigability and deployment in tortuous vessels and therefore are optimal for the cerebral circulation. SES were initially used for stent-assisted coil embolization of intracranial aneurysms and for treatment of intracranial stenosis. However, a few authors have recently reported feasibility of deployment of SES in AIS. The use of these devices yielded higher recanalization rates compared to traditional thrombectomy devices. Encouraged by these results, retrievable SES systems have been recently used in AIS. These devices offer the advantage of resheathing and retrieving of the stent even after full deployment. Some of these stents can also be detached in case permanent stent placement is needed. Retrievable SES are being used in Europe and currently tested in clinical trials in the United States. We review the recent literature in the use of stents for the treatment of AIS secondary to large vessel occlusion.

Background and Purpose: Endovascular treatment of tandem occlusions is an emerging option. We describe our multicenter experience with endovascular management of atherosclerotic tandem occlusions in the anterior circulation, particularly the technical aspects and complications in comparison to isolated intracranial occlusions. Materials and Methods: Consecutive patients with tandem occlusions due to atherosclerotic causes who underwent mechanical thrombectomy at two major stroke centers between January 2010 and September 2015 were reviewed. Clinical data, procedural aspects, recanalization rates, complication rates, and clinical outcome were analyzed and compared to findings in patients with isolated intracranial occlusions. Results: One hundred and twenty-one patients with tandem occlusions and 456 patients with isolated intracranial occlusions (carotid-T/M1) were included. Mean intervention time was faster (33 min vs. 57 min, p < 0.001) and recanalization success was higher (TICI 2b/3 83.6 vs. 70.2%, p = 0.002) in patients with isolated occlusions. No difference was seen in clinical outcome and complications, except for a higher rate of asymptomatic hemorrhage in the tandem group (29.8 vs. 17.1%, p = 0.003). Choice of recanalization approach (antegrade vs. retrograde) in the tandem group made no difference, except for a trend toward less distal emboli using the retrograde approach (4.0 vs. 13.0%, p = 0.082). Stenting of the extracranial internal carotid artery (ICA) was performed in 81%, PTA alone in 7.4%, and deferred stenting in 11.6%. Rate of stent/ICA occlusion within 7 days was 10.3% after stenting and 33.3% after PTA ( p = 0.127). In the tandem group, age ( p = 0.034), National Institutes of Health Stroke Scale score (NIHSS) at admission ( p = 0.002), recanalization rate ( p < 0.001), complications ( p = 0.016), and symptomatic intracranial hemorrhage (sICH) ( p = 0.001) were associated with poor outcome, whereas extracranial treatment modality and stent/ICA occlusion within 7 days did not affect outcome. Conclusion: Endovascular treatment of tandem occlusions is technically feasible, achieves recanalization rates and rates of good clinical outcome comparable to those in patients with isolated intracranial occlusions. Following acute ICA stenting, the risk of stent occlusion and sICH appeared to be low, but was associated with an increased rate of asymptomatic ICH.

Intracranial atherosclerotic disease (ICAD) accounts for 33-50% of all ischemic strokes in the Asian population (1) and represents an important public health issue in China. The results of the SAMMPRIS trial alarmed most experienced interventionalists in China for two reasons. Firstly, the high complication rate in the stenting arm (20% the first year) was higher than expected. Secondly, the recurrent stroke rate in the aggressive medical treatment arm at 12.2% during the first year was unacceptably high, not to mention the fact that such tight vascular risk factor control is difficult to achieve for many patients in real life clinical experience, at least in China. The experience of treating ICAD in China, gained over the last two decades, is very rich and promising. We intend to highlight these past experiences and address future trials and trends in China. We will also address our criticism of the SAMMPRIS trial design in order to better design a future trial.

Recanalization of acute large artery occlusions is a strong predictor of good outcome. The development of thrombectomy devices resulted in a significant improvement in recanalization rates compared to thrombolytics alone. However, clinical trials and registries with these thrombectomy devices in acute ischemic stroke (AIS) have shown recanalization rates in the range of 40-81%. The last decade has seen the development of nickel titanium self-expandable stents (SES). These stents, in contrast to balloon-mounted stents, allow better navigability and deployment in tortuous vessels and therefore are optimal for the cerebral circulation. SES were initially used for stent-assisted coil embolization of intracranial aneurysms and for treatment of intracranial stenosis. However, a few authors have recently reported feasibility of deployment of SES in AIS. The use of these devices yielded higher recanalization rates compared to traditional thrombectomy devices. Encouraged by these results, retrievable SES systems have been recently used in AIS. These devices offer the advantage of resheathing and retrieving of the stent even after full deployment. Some of these stents can also be detached in case permanent stent placement is needed. Retrievable SES are being used in Europe and currently tested in clinical trials in the United States. We review the recent literature in the use of stents for the treatment of AIS secondary to large vessel occlusion.