World Neurosurgery

2017

DOI: 10.1016/j.wneu.2016.09.106

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Effectiveness of Intracranial Percutaneous Transluminal Angioplasty or Stenting for Atherosclerotic Vertebrobasilar Artery Occlusion in the Acute Phase of Ischemic Stroke

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Ichiro Nakagawa

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et al.

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“…Acute vertebrobasilar artery occlusion is a life-threatening condition and requires immediate treatment. Despite recent advances in stroke care, the rate of poor outcomes for those with vertebrobasilar artery occlusion remains high ( 11 ). In 2016, a meta-analysis of 5 recent landmark endovascular therapy trials confirmed the superiority and better outcomes of mechanical thrombectomy in large-vessel occlusion for acute anterior circulation strokes ( 12 ).…”

Section: Discussionmentioning

confidence: 99%

Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage

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²

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³

et al. 2021

Front. Neurol.

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Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion.Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period.Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status.Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.

“…Acute vertebrobasilar artery occlusion is a life-threatening condition and requires immediate treatment. Despite recent advances in stroke care, the rate of poor outcomes for those with vertebrobasilar artery occlusion remains high ( 11 ). In 2016, a meta-analysis of 5 recent landmark endovascular therapy trials confirmed the superiority and better outcomes of mechanical thrombectomy in large-vessel occlusion for acute anterior circulation strokes ( 12 ).…”

Section: Discussionmentioning

confidence: 99%

Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage

¹

,

²

,

³

et al. 2021

Front. Neurol.

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Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion.Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period.Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status.Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.

“…Comparability: There was comprehensive matching for all plausible prognostic variables in 12 studies [ 31 - 42 ], so we considered them as low risk of bias. However, this item was not mentioned clearly in the remaining 10 studies [ 13 , 22 , 43 - 50 ], so we considered them of unclear risk of bias.…”

Section: Reviewmentioning

confidence: 99%

“…As for follow-up, all studies are of low risk of bias. Regarding the adequacy of cohorts' follow-up, 13 studies [ 13 , 22 , 32 - 34 , 37 , 40 , 42 , 44 , 45 , 47 , 48 , 50 ] reported adequate details suggesting no missing data or the missed data is not enough to have a significant impact on the intervention. Therefore, they were considered at low risk of bias.…”

Section: Reviewmentioning

confidence: 99%

“…Due to the lack of data from randomized clinical trials, decisions regarding extradural occlusion are mostly dependent upon clinician judgment. In addition to risk factor modification, management options include single antiplatelet therapy and PTAS [ 13 ]. Unfortunately, antithrombotic agents and intravenous thrombolytics have yielded poor results in achieving recanalization of affected vasculature [ 14 - 18 ].…”

Section: Introductionmentioning

confidence: 99%

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Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints

Nso¹,

et al. 2022

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Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone.

“…1,2) Currently, evidence is primarily obtained from observational studies, but the number of reports on posterior circulation occlusion remains small. [3][4][5][6][7][8] However, the results of medical treatment in atherothrombotic brain infarction (ATBI) patients with vertebrobasilar artery occlusion are not always favorable. At our hospital, acute-phase PTA/ PTAS are actively performed.…”

Section: Introductionmentioning

confidence: 99%

Initial Results of Percutaneous Transluminal Angioplasty/Stenting for Vertebrobasilar Occlusion due to Atherothrombotic Disease during Acute Phase

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³

et al. 2021

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The efficacy and safety of acute percutaneous transluminal angioplasty or stenting (PTA/PTAS) for vertebrobasilar artery occlusion with atherothrombotic brain infarction (ATBI) have not been confirmed despite the resistance to medical therapy alone. There are few reports about this disease and its treatment. Therefore, the treatment outcomes at our hospital were summarized to evaluate the efficacy and safety. Methods: This was a retrospective study of acute PTA/PTAS for vertebrobasilar artery occlusion due to atherosclerotic change in 19 consecutive patients with a modified Rankin Scale (mRS) score of 0-2 before stroke between March 2010 and December 2018. The factors related to prognosis were investigated. Outcomes were assessed at 90 days of follow-up. Results: Of 19 patients with acute vertebrobasilar artery occlusion treated by PTA/PTAS, 8 had good outcomes (mRS 0-2) and 11 had poor outcomes (mRS 3-6). There were no differences in the clinical or patient background except for the National Institutes of Health Stroke Scale (NIHSS) score between groups. The good outcome group had a lower NIHSS score than the poor outcome group (median: 9.5 vs 35, p <0.001). The Thrombolysis in Cerebral Ischemia (TICI) 2b-3 group had a slightly more favorable outcome than the TICI0-2a group (p = 0.10). There were no differences in outcome between PTA and PTAS groups (p = 0.65). Conclusion: Reperfusion of the posterior circulation by PTA/PTAS may be necessary for a good outcome. Although acute stenting must be performed under careful observation, a stent can be placed when recurrence in the early phase is estimated with high probability. Keywords▶ vertebrobasilar occlusion, atherosclerotic change, ATBI, acute phase, PTA/PTAS This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

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