How Effective Is Endovascular Intracranial Revascularization in Stroke Prevention? Results from Borgess Medical Center Intracranial Revascularization Registry

Abstract

BACKGROUND AND PURPOSE:The WASID study established the risk of subsequent ischemic stroke at 1 year in subjects with symptomatic intracranial atherosclerotic stenosis (70%-99%) at 18%. The efficacy of different methods of endovascular revascularization in stroke prevention still has not been established. We compared the stroke rate in our registry at 1 year following intervention with the WASID results to identify which method, if any, provides the most benefit in stroke prevention. This result from the BMC-IRR follows a previously published article comparing stent placement and angioplasty outcomes.

The Technique of Endovascular Intracranial Revascularization

“…Clinical results have shown that modest angioplasty results produce satisfactory clinical results (8–11, 13, 14). A review of our experience over the last 7 years reveals that 121 procedures were performed.…”

“…A longer balloon will typically straighten the vessel, thus, stretching the shorter length of the inner curvature and possibly causing a dissection. The balloon diameter is undersized relative to the vessel diameter by 0.25–0.5 mm as previously described (8–11). In most cases, an over-the-wire system is utilized due to superior tracking ability, more sensitive “push–pull,” and appreciably more accurate control of the microguidewire when compared with a rapid exchange (monorail) system.…”

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

“…Factors of compliance are related to the treating physicians, patients and medical systems. 159–163 Research has shown that compliance with secondary stroke prevention therapy in patients with ischemic stroke or TIA is poor once they are discharged. 160,161,164 The CNSR data showed that only 63.6% of patients continued to take all secondary preventive drugs prescribed at the time of discharge three months thereafter.…”

Intracranial Angioplasty and Stenting before and after SAMMPRIS: “From Simple to Complex Strategy – The Chinese Experience”

“…Besides the stent itself, we believe that there was another shortcoming in the trial design (19). Dissection following angioplasty has been shown in a prospective registry to predict a higher stroke rate in the peri-procedural period (20, 21). Since the slow inflation technique of the angioplasty balloon was not included in the trial protocol, and no angiogram following the angioplasty was obtained prior to the stent placement, we can speculate that some of the complications in SAMMPRIS were due to unaccounted dissections caused by suboptimal angioplasty technique (7, 13, 17, 19).…”

“…Since the slow inflation technique of the angioplasty balloon was not included in the trial protocol, and no angiogram following the angioplasty was obtained prior to the stent placement, we can speculate that some of the complications in SAMMPRIS were due to unaccounted dissections caused by suboptimal angioplasty technique (7, 13, 17, 19). Secondly, in SAMMPRIS all the vessels were grouped together without distinction between vessels with perforators (BA, MCA) and those without perforators (VA, ICA), despite their known different complication rates (20, 21). Thirdly, the SAMMPRIS protocol did not take into account the Mori classification, yet there are numerous papers showing that lesions with different characteristics as classified by Mori carry different risks during intracranial endovascular revascularization (IER) (20–26).…”