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ABSTRACT BACKGROUND There are limited data on outcomes of extracranial-intracranial (EC-IC) bypass in patients with recurrent hemispheric syndromes due to atherosclerotic internal carotid artery occlusion (AICAO). OBJECTIVE To compare clinical outcomes and efficacy of EC-IC bypass surgery in patients with and without recurrent hemispheric syndromes associated with AICAO in the Carotid Occlusion Surgery Study (COSS). METHODS In patients enrolled in the COSS trial, we compared baseline characteristics and clinical outcomes for participants with (rHEMI+) and without recurrent hemispheric ischemia (rHEMI−) prior to randomization into surgical vs medical groups. The primary outcome was all stroke and death from randomization through 30 d and ipsilateral ischemic stroke within 2 yr. RESULTS Of 195 randomized participants, 100 were rHEMI+ (50 in each group). Baseline characteristics between rHEMI+ and rHEMI− participants were similar except rHEMI+ were more likely to have had previous stroke prior to randomization (61% vs 20%, P < .01) and to have TIA as the entry event (59% vs 21%, P < .01). All primary endpoints were ipsilateral ischemic strokes. There were no significant differences in occurrence of the primary endpoint between nonsurgical and surgical participants in rHEMI+ (26.3% vs 22.4%, P = .660) and rHEMI− (18.9% vs 19.5%, P = .943). For nonsurgical participants, there was no significant difference in the primary endpoint for rHEMI+ vs rHEMI− patients (P = .410) CONCLUSION Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial did not show benefit from EC-IC bypass compared to medical treatment. Early aggressive risk factor measures should be prioritized to reduce recurrent strokes in these patients.

BackgroundCarotid blowout syndrome is a serious complication of head and neck cancer (HNC) that may involve the intracranial or extracranial internal carotid artery (ICA). Although parent artery occlusion (PAO) is the major endovascular treatment for intracranial carotid blowout syndrome (iCBS), the efficacy of using a balloon-expandable coronary stent-graft (BES) remains unclear.MethodsThis was a quasi-randomized trial, prospective study that included patients with iCBS treated by BES or PAO between 2018 and 2024. Patients were allocated to either group based on the last digit of their chart number; even numbers went to the BES group and odd numbers to the PAO group. The inclusion criteria of iCBS included the pathological process of CBS involving petrous and/or cavernous ICA detected by both imaging and clinical features. The primary outcome was defined as rebleeding events after intervention. The secondary outcome was defined as neurological complication after intervention.ResultsFifty-nine patients with 61 iCBS lesions were enrolled. Thirty-three iCBS lesions were treated with BES and 28 underwent PAO. The results for the BES group versus the PAO group, respectively, were: rebleeding events, 5/33 (15.1%) vs 5/28 (17.8%) (p=0.78); neurological complication, 5/33 (15.1%) vs 5/28 (17.8%) (p=0.78); median hemostatic time (months), 10.0 vs 11.5 (p=0.22); and median survival time (months), 10.0 vs 11.5 (p=0.39).ConclusionsNo significant difference in rebleeding risk or neurological complication was observed between the BES and PAO groups. Our study confirmed the safety and effectiveness of applying BES for iCBS in HNC patients.

A 62-year-old man was presented with transient ischemic attack 1 day after percutaneous coronary intervention. Magnetic resonance imaging demonstrated fresh cerebral infarction in the left hemisphere. Digital subtraction angiography showed left Riles type 1A common carotid artery occlusion (CCAO). Blood flow in the internal carotid artery (ICA) was derived from the external carotid artery, which came through the anastomosis between the left occipital artery and a muscular branch of left vertebral artery. We performed short jump graft from CCA to ICA using saphenous vein, followed by ligation of CCA. The graft remained patent at the 1-year follow-up.

BackgroundIt is debated whether endovascular treatment is indicated for a symptomatic chronically occluded internal carotid artery (COICA).ObjectiveTo assess outcomes after endovascular treatment of COICA.MethodsWe performed a systematic search of three databases (PRISMA guidelines), including endovascular series of COICA. Outcomes were analyzed with random-effects models.ResultsWe included 13 studies and 528 endovascularly treated patients with COICA. Successful recanalization was 72.6% (347/528, 95% CI 65.4% to 79.9%, I2=68.9%). Complications were 18% (88/516, 95% CI 12.1% to 23.8%, I2=65%), with 5% (25/480, 95% CI 2% to 7%, I2=0%) of permanent events, and 9% (43/516, 95% CI 6% to 13%, I2=34%) of thromboembolisms. Treatment-related mortality was 2% (11/516, 95% CI 0.5% to 2.6%, I2=0%). Shorter duration of the occlusion was associated with higher recanalization: 80% (11/516, 95% CI 54% to 89%, I2=0%), 63% (33/52, 95% CI 49% to 76%, I2=0%), and 51% (18/35, 95% CI to 37% to 88%, I2=40%) recanalization rates for 1, 3, and >3 months occlusions, respectively. Complications were 6% (3/50, 95% CI 3% to 21%, I2=0%), 14% (4/27, 95% CI 5% to 26%, I2=0%), and 25% (13/47, 95% CI 10% to 30%, I2=0%) for 1, 3, and >3 months occlusions, respectively. Patient aged <70 years presented higher revascularization rates (OR=3.1, 95% CI 1.2 to 10, I2=0%, p=0.05). Successful reperfusion was higher (OR=5.7, 95% CI 1.2 to 26, I2=60%, p=0.02) and complications were lower (OR=0.2, 95% CI 0.6 to 0.8, I2=0%, p=0.03) for lesions limited to the cervical internal carotid artery compared with the petrocavernous segment. Successful recanalization significantly lowered the rate of thromboembolisms (OR=0.2, 95% CI 0.8 to 0.6, I2=0%, p=0.01) and mortality (OR=0.5, 95% CI 0.1 to 0.9, I2=0%, p=0.04), compared with conservative treatment.ConclusionsEndovascular treatment of COICA gives a 70% rate of successful recanalization, with 5% morbidity. Patients aged <70 years, lesions limited to the cervical internal carotid artery, and a shorter duration of the occlusion decreased the risk of complications. Successful recanalization of symptomatic lesions lowered by about 80% the likelihood of thromboembolisms, compared with medical management.

BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the internal carotid artery (ICA), covering the A1 segment, have rarely been investigated. We aimed to provide angiographic and clinical data about flow modifications on the covered A1.MethodsConsecutive patients receiving M1-ICA flow diverters for unruptured aneurysms were collected from our prospective database (2014–2020).Results42 A1 arteries covered with a single device were studied. All patients had an angiographic detected contralateral flow from the anterior communicating artery (AcomA). Immediately after flow diversion, 20 (47.6%) covered A1 showed slow flow. During a mean angiographic follow-up of 14 months, 13 (31%) and 22 (52.3%) A1 arteries were occluded and narrowed, respectively. Flow changes were asymptomatic in all cases. Vascular risk factors, sex, oversized compared with not oversized stents, immediate A1 slow flow, age, diameter of the A1, length of follow-up, and platelet inhibition rate were tested as prognosticators of A1 occlusion. Length of the angiographic follow-up was the only predictor of A1 occlusion (p=0.005, OR=3, CI=1.4 to 6.7). There were two device related ischemic events with a 2.3% rate of morbidity (one basal ganglia infarct after coverage of the M1 perforators and one transient acute instent thrombosis).ConclusionsCovering the A1 segment during M1-ICA flow diversion seems relatively safe, if the contralateral flow is assured by the AcomA. Approximately 31% and 52% of the covered A1 showed asymptomatic occlusions and narrowing, respectively. The likelihood of flow modification was proportional to the length of follow-up. Morbidity associated with flow diversion in the ICA terminus region was 2.3%.

Transient ischemic attacks (TIAs) often herald a stroke, but little is known about the acute natural history of TIAs. Our objective was to quantify the early risk of stroke after a TIA in patients with internal carotid artery disease. Using patient data from the medical arm of the North American Symptomatic Carotid Endarterectomy Trial, we calculated the risk of ipsilateral stroke in the territory of the symptomatic internal carotid artery within 2 and 90 days after a first-recorded hemispheric TIA. We also studied similar outcomes among patients in the trial who had a first-recorded completed hemispheric stroke. For patients with a first-recorded hemispheric TIA (n = 603), the 90-day risk of ipsilateral stroke was 20.1% (95% confidence interval [CI] 17.0%-23.2%), higher than the 2.3% risk (95% CI 1.0%-3.6%) for patients with a hemispheric stroke (n = 526). The 2-day risks were 5.5% and 0.0%, respectively. Patients with more severe stenosis of the internal carotid artery (> 70%) appeared to be at no greater risk of stroke than patients with lesser degrees of stenosis (adjusted hazard ratio 1.1, 95% CI 0.7-1.7). Infarct on brain imaging (adjusted hazard ratio 2.1, 95% CI 1.5-3.0) and the presence of intracranial major-artery disease (adjusted hazard ratio 1.9, 95% CI 1.3-2.7) doubled the early risk of stroke in patients with a hemispheric TIA. Patients who had a hemispheric TIA related to internal carotid artery disease had a high risk of stroke in the first few days after the TIA. Early risk of stroke was not affected by the degree of internal carotid artery stenosis.

The SPACE trial is a multinational, prospective, randomised study to test the hypothesis that carotid artery stenting is not inferior to carotid endarterectomy for treating patients with severe symptomatic carotid artery stenosis. We did not prove non-inferiority of carotid artery stenting compared with carotid endarterectomy for the 30-day complication rate, and we now report the results at 2 years. Between March, 2001, and February, 2006, patients with symptomatic, severe (≥70%) carotid artery stenosis were recruited to this non-inferiority trial and randomly assigned with a block randomisation design to have carotid artery angioplasty with stenting or carotid artery endarterectomy. 2-year endpoints include several clinical endpoints and the incidence of recurrent carotid stenosis of at least 70%. Clinical and vascular follow-up was done by a certified neurologist. Analyes were by intention to treat and per protocol. This trial is registered with ISRCTN, number 57874028.12. 1 214 patients were randomly assigned (613 were randomly assigned to carotid angioplasty with stenting and 601 were randomly assigned to carotid endarterectomy). In both the intention-to-treat and per-protocol analyses the Kaplan-Meier estimates of ipsilateral ischaemic strokes up to 2 years after the procedure and any periprocedural stroke or death do not differ between the carotid artery stenting and the carotid endarterectomy groups (intention to treat 9·5% vs 8·8%; hazard ratio (HR) 1·10, 95%CI 0·75 to 1·61; log-rank p=0·62; per protocol 9·4% vs 7·8%; HR 1·23, 95%CI 0·82 to 1·83; log-rank p=0·31). In both the intention-to-treat and per-protocol populations, recurrent stenosis of 70% or more is significantly more frequent in the carotid artery stenting group compared with the carotid endarterectomy group, with a life-table estimate of 10·7% versus 4·6% (p=0·0009) and 11·1% versus 4·6% (p=0·0007), respectively. Only two incidences of recurrent stenoses after carotid artery stenting led to neurological symptoms. After 2 years' follow-up, the rate of recurrent ipsilateral ischaemic strokes reported in the SPACE trial is similar for both treatment groups. The incidence of recurrent carotid stenosis at 2 years, as defined by ultrasound, is significantly higher after carotid artery stenting. However, it cannot be excluded that the degree of in-stent stenosis is slightly overestimated by conventional ultrasound criteria. Federal Ministry of Education and Research; German Research Foundation; The German Society of Neurology; The German Society of Neuroradiology; The German Radiological Society; Boston Scientific; Guidant; Sanofi-Aventis.

Abstract Objective Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. Symptomatic lesions are resistant to medical treatment and revascularization is often required, but there is no consensus on the treatment of CCAO at present. Riles type 1A CCAO is most likely to benefit from revascularization because it has patent outflow tract (internal carotid artery) which was supplied by patent external carotid artery (ECA) from collateral circulation. We described a novel surgical technique improved on the basis of the carotid endarterectomy (CEA) for treatment of Riles type 1A CCAO.MethodsWe rigorously screened ten patients with symptomatic Riles type1A CCAO for surgery from January 2017 to May 2019 and performed a full preoperative assessment of the inadequate collateral circulation compensation. Moreover, we retrospectively reviewed our experience of the segmented CEA in the treatment of them in our single center.ResultsSegmented CEA was performed on the left side in four cases and on the right side in six cases. The technical success rate of the procedure was 100%. Primary suture was used in nine cases. Only one patient (right CCAO) who had a history of neck radiotherapy was treated by the patch CEA. The mean temporary blocking time during surgery was 52.8 ± 9.15 min. The mean temporary blocking time for treating the upper segment of the common carotid artery (CCA) was 11.1 ± 2.64 min. In the postoperative period, cerebral perfusion on the ipsilateral site improved in all patients, myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another. No ischemic events or re-occlusion or restenosis (> 50%) of the treated CCA occurred during the mean follow-up of 32.6 ± 9.3 months. The preoperative mean modified Rankin Scale (mRS) score was 1.9 (range, 1–3; median, 2). At last follow-up for all patients, the mRS score was 1 (range, 0–3; median, 1).ConclusionSegmented CEA, which utilizes the compensatory effect of collateral circulation, is an effective and safe technique to treat patients suffering from Riles type 1A CCAO with hemodynamic cerebrovascular compromise.

Tenecteplase for thrombolysis in a 4.5-to-24-hour window did not improve disability outcomes at 90 days in patients with ischemic stroke who had been chosen on the basis of imaging. Most patients had endovascular thrombectomy.

Background and purposeCarotid artery stenting is an alternative to endarterectomy for the treatment of symptomatic carotid stenosis but was associated with a higher risk of procedural stroke or death in randomized controlled trials (RCTs). Technical aspects of treatment may partly explain these results. The purpose of this analysis was to investigate the influence of technical aspects such as stent design or the use of protection devices, as well as clinical variables, on procedural risk.MethodsWe pooled data of 1557 individual patients receiving stent treatment in three large RCTs comparing stenting versus endarterectomy for symptomatic carotid stenosis. The primary outcome event was any procedural stroke or death occurring within 30 days after stenting.ResultsProcedural stroke or death occurred significantly more often with the use of open-cell stents (61/595 patients, 10.3%) than with closed-cell stents (58/962 patients, 6.0%; RR 1.76; 95% CI 1.23 to 2.52; P=0.002). Procedural stroke or death occurred in 76/950 patients (8.0%) treated with protection devices (predominantly distal filters) and in 43/607 (7.1%) treated without protection devices (RR 1.10; 95% CI 0.71 to 1.70; P=0.67). Clinical variables predicting the primary outcome event were age, severity of the qualifying event, history of prior stroke, and level of disability at baseline. The effect of stent design remained similar after adjustment for these variables.ConclusionsIn symptomatic carotid stenosis, the use of stents with a closed-cell design is independently associated with a lower risk of procedural stroke or death compared with open-cell stents. Filter-type protection devices do not appear to reduce procedural risk.