Encephaloduroarteriosynangiosis Averts Stroke in Atherosclerotic Patients With Border-Zone Infarct: Post Hoc Analysis From a Performance Criterion Phase II Trial

Abstract

BACKGROUND Intracranial atherosclerotic disease (ICAD) is one of the leading causes of stroke worldwide. Patients with ICAD who initially present with ischemia in border-zone areas and undergo intensive medical management (IMM) have the highest recurrence rates (37% at 1 yr) because of association with hemodynamic failure and poor collaterals. OBJECTIVE To evaluate the effect of encephaloduroarteriosynagiosis (EDAS) on stroke recurrence in patients with ICAD and border-zone stroke (BDZS) at presentation. METHODS A phase II clinical trial of EDAS revascularization for symptomatic ICAD failing medical management (EDAS Revascularization for Symptomatic Intracranial Atherosclerosis Steno-occlusive [ERSIAS]) was recently concluded. We analyze the outcomes of the subgroup of patients with BDZS at presentation treated with EDAS vs the previously reported Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) IMM subgroup with BDZS at presentation. RESULTS Of 52 patients included in the ERSIAS trial, 35 presented with strokes at baseline, and 28 had a BDZ pattern, including 15 (54%) with exclusive BDZS and 13 (46%) with mixed patterns (BDZ plus other distribution). Three of the 28 (10.7%) had recurrent strokes up to a median follow-up of 24 months. The rate of recurrent stroke in ICAD patients with BDZS at presentation after EDAS was significantly lower than the rate reported in the SAMMPRIS IMM subgroup with BDZS at presentation (10.7% vs 37% P = .004, 95% CI = 0.037-0.27). CONCLUSION ICAD patients with BDZS at presentation have lower rates of recurrent stroke after EDAS surgery than those reported with medical management in the SAMMPRIS trial. These results support further investigation of EDAS in a randomized clinical trial.

Encephaloduroarteriosynangiosis Operative Technique and Intraoperative Anesthesia Management: Treatment From Both Sides of the Curtain

“…Although the EDAS technique has been described several times in the literature, no reports have evaluated the multidisciplinary approach to improve operative outcomes and the effects of maintaining strict medical management in patients at high risk of recurrent stroke. As the role of EDAS potentially expands to treat conditions such as ICAD, 3,5,7,21 it is necessary to identify the detailed nuances and variables that can be controlled to ensure good outcomes.…”

Roundtable of Academia and Industry for Stroke Prevention: Prevention and Treatment of Large-Vessel Disease

“…66 Finally, data from the ERSIAS study (Surgical Indirect Revascularization for Symptomatic Intracranial Arterial Stenosis) showed that in patients with symptomatic ICAD and border zone infarction, encephalo-duro-arterio-synangiosis seems to be safe with 10.7% recurrent stroke at 24 months. 67 Due to safety concerns with angioplasty/stenting, current guidelines 19 and the FDA recommend against its use as a first-line treatment for patients with ICAD; thus, it is currently considered only in those who had 2 or more strokes despite optimal medical treatment. 64 Identifying a subgroup of ICAD patients risk stratified using biomarkers of impaired distal blood flow/perfusion and whose 90-day recurrent stroke is higher than that of stenting may help identify a high-risk group of patients with ICAD with a high recurrent stroke risk despite optimal medical treatment.…”

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

“…The rates of early stroke were also nominally lower than in previous studies of direct bypass and angioplasty/stenting, reaching the prespecified threshold set for advancement to phase III study. 59,83 An additional prospective comparative study of EDAS in intracranial atherosclerotic disease resulting in MCA occlusion by Zhang et al 58 also showed a nominal reduction in rates of stroke and death with EDAS, although this effect did not reach statistical significance due to the limited sample size.…”