Fengshui Zhu

Treatment of symptomatic middle cerebral artery stenosis with balloon-mounted stents: long-term follow-up at a single center.

OBJECTIVEPrimary stenting is a well-established treatment for coronary artery disease and has been applied to symptomatic intracranial stenosis in selected patients. This study reports a large case series of middle cerebral artery revascularization using balloon-mounted coronary stents. METHODSThe series consisted of 113 consecutive patients with symptomatic middle cerebral artery stenosis and more than 70% occlusion who underwent intracranial stenting at a single center from 2001 to 2006. Technical success, periprocedural complications, recurrent symptoms, and restenosis were retrospectively reviewed. Risk factors for restenosis were analyzed using logistic regression and the χ2 test. RESULTSThe mean age of the patients was 48 ± 11 years (range, 25–79 years). Seventy-three patients presented with transient ischemic attacks, and 40 patients were diagnosed with acute stroke. The technical success rate was 96.46%. The mean stenosis was reduced from 80.83 ± 8.77% to 3.71 ± 8.15%. The rate of stroke and death within 30 days was 4.42%. Eighty-nine patients were followed for an average period of 29 ± 16 months (range, 9 months–5 years). Seventy-nine vessels were followed with transcranial Doppler and 36 vessels with angiography or computed tomographic angiography. Recurrent stroke or transient ischemic attacks occurred in 6 patients (6.74%). The restenosis rate was 20.25%. Restenosis was associated with diabetes and hyperlipidemia but not with age, sex, hypertension, or drug-eluting stent. CONCLUSIONPrimary stenting of symptomatic middle cerebral artery stenosis can be performed with high success and low complication rates. Randomized clinical studies are warranted to compare the safety and efficacy of various endovascular revascularization techniques with maximal medical therapy in patients with symptomatic intracranial atherosclerosis.

China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS): A new, prospective, multicenter, randomized controlled trial in China

Background Patients with symptomatic stenosis of intradural arteries are at high risk for subsequent stroke. Since the SAMMPRIS trial, stenting is no longer recommended as primary treatment; however, the results of this trial, its inclusion criteria and its center selection received significant criticism and did not appear to reflect our experience regarding natural history nor treatment complications rate. As intracranial atherosclerosis (ICAS) is the most common cause for stroke in Asian countries, we are hereby proposing a refined prospective, randomized, multicenter study in an Asian population with strictly defined patient and participating center inclusion criteria. Methods The China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) trial is an ongoing, government-funded, prospective, multicenter, randomized trial. It recruits patients with recent TIA or stroke caused by 70%–99% stenosis of a major intracranial artery. Patients with previous stroke related to perforator ischemia will not be included. Only high-volume centers with a proven track record will enroll patients as determined by a lead-in phase. Patients will be randomized (1:1) to best medical therapy alone or medical therapy plus stenting. Primary endpoints are any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days. The CASSISS trial will be conducted in eight sites in China with core imaging lab review at a North American site and aims to have a sample size of 380 participants (stenting, 190; medical therapy, 190). Recruitment is expected to be finished by December 2016. Patients will be followed for at least three years. The trial is scheduled to complete in 2019. Conclusion In the proposed trial, certain shortcomings of SAMMPRIS including patient and participating center selection will be addressed. The present manuscript outlines the rationale and design of the study. We estimate that this trial will allow for a critical reappraisal of the role of intracranial stenting for selected patients in high-volume centers.

Randomized controlled trial of symptomatic middle cerebral artery stenosis: endovascular versus medical therapy in a Chinese population.

Background and Purpose— To investigate the efficacy and safety of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic middle cerebral artery stenosis compared with standard medical treatment in a low-risk Chinese population. Methods— A prospective, randomized, controlled, single-center clinical trial was conducted comparing PTAS with medical treatment for symptomatic middle cerebral artery stenosis (≥70%). Patients were enrolled according to 1:1 enroll ratio (PTAS: medical). The PTAS group received stenting or balloon angioplasty, whereas the medical treatment group received standard medical treatment (aspirin 100mg plus clopidogrel 75mg/d), and all the patients were under strict control of the risk factors. The end point events were any kind of ipsilateral stroke or transient ischemic attack, or death from any origin during 1-year follow-up. Results— The enrollment was stopped after 70 patients were enrolled from August 2007 to December 2010, with a 30-day rate of end point events of 8.3% versus 5.9% (P=0.69) for PTAS and medical group, respectively, and 1-year rate of end point events of 19.4% versus 17.6% (P=0.85), respectively. There was no significant difference in baseline characteristics between the 2 groups. The mean follow-up time, which was ongoing, was 9.9 ± 3.9 and 9.7 ± 4.4 months, respectively. Among the risk factors, hypertension was the independent related to the outcome (P=0.015). Conclusions— This study showed that endovascular treatment is as safe but not better than medical treatment for symptomatic middle cerebral artery stenosis in a low-risk Chinese population. History of hypertension increases the risk of recurrent ischemic events.

Safety and Efficacy of Remote Ischemic Preconditioning in Patients with Severe Carotid Artery Stenosis Prior to Carotid Artery Stenting: A Proof-of-Concept, Randomized Controlled Trial

Background: Remote ischemic preconditioning (RIPC) can inhibit recurrent ischemic events effectively in patients with acute or chronic cerebral ischemia. However, it is still unclear whether RIPC can impede ischemic injury after carotid artery stenting (CAS) in patients with severe carotid artery stenosis. Methods: Subjects with severe carotid artery stenosis were recruited in this randomized controlled study, and assigned to RIPC, sham, and no intervention (control) groups. All subjects received standard medical therapy. Subjects in the RIPC and sham groups underwent RIPC and sham RIPC twice daily, respectively, for 2 weeks before CAS. Plasma neuron-specific enolase and S-100B were used to evaluate safety, hypersensitive C-reactive protein, and new ischemic diffusion-weighted imaging lesions were used to determine treatment efficacy. The primary outcomes were the presence of ≥1 newly ischemic brain lesions on diffusion-weighted imaging within 48 hours after stenting and clinical events within 6 months after stenting. Results: We randomly assigned 189 subjects in this study (63 subjects in each group). Both RIPC and sham RIPC procedures were well tolerated and completed with high compliance (98.41% and 95.24%, respectively). Neither plasma neuron-specific enolase levels nor S-100B levels changed significantly before and after treatment. No severe adverse event was attributed to RIPC and sham RIPC procedures. The incidence of new diffusion-weighted imaging lesions in the RIPC group (15.87%) was significantly lower than in the sham group (36.51%; relative risk, 0.44; 96% confidence interval, 0.20–0.91; P<0.01) and the control group (41.27%; relative risk, 0.39; 96% confidence interval, 0.21–0.82; P<0.01). The volumes of lesions were smaller in the RIPC group than in the control and sham groups (P<0.01 each). Ischemic events that occurred after CAS were 1 transient ischemic attack in the RIPC group, 2 strokes in the control group, and 2 strokes and 1 transient ischemic attack in the sham group, but these results were not significantly different among the 3 groups (P=0.597). Conclusions: RIPC is safe in patients undergoing CAS, which may be able to decrease ischemic brain injury secondary to CAS. However, the mechanisms and effects of RIPC on clinical outcomes in this cohort of patients need further investigation. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01654666

Multicenter Prospective Trial of Stent Placement in Patients with Symptomatic High-Grade Intracranial Stenosis

BACKGROUND AND PURPOSE: On the basis of the high 1-month stroke and/or death (14.7%) rates associated with stent placement in the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, modifications in patient selection and procedural aspects for intracranial stent placement have been recommended. We performed a multicenter prospective single-arm trial to determine whether such modifications would result in lower rates of periprocedural stroke and/or death. MATERIALS AND METHODS: The study enrolled patients with recent transient ischemic attack or ischemic stroke (excluding perforator ischemic events) related to high-grade (70%–99% in severity) stenosis of a major intracranial artery. Patients were treated by using angioplasty and self-expanding stents 3 weeks after the index ischemic event at 1 of the 10 high-volume centers in China. An independent neurologist ascertained the occurrence of any stroke and/or death within 1 month after the procedure. RESULTS: A total of 100 consecutive patients were recruited. The target lesions were located in the middle cerebral artery (M1) (n = 38, 38%), intracranial internal carotid artery (n = 17, 17%), intradural vertebral artery (n = 18, 18%), and basilar artery (n = 27, 27%). The technical success rate of stent deployment with residual stenosis of <50% was 100%. The overall 1-month stroke and/or death rate was 2% (95% confidence interval, 0.2%–7.0%). Two ischemic strokes occurred in the pontine region (perforator distribution) in patients following angioplasty and stent placement for basilar artery stenosis. CONCLUSIONS: The results of this prospective multicenter study demonstrated that modifications in patient selection and procedural aspects can substantially reduce the 1-month stroke and/or death rate following intracranial stent placement.

Intra-arterial thrombolysis for acute central retinal artery occlusion.

Abstract Objective: In this study, we aimed at exploring the effect and safety of local intra-arterial thrombolysis on acute central retinal artery occlusion. Methods: Retrospective data analysis of 49 consecutive acute central retinal occlusion patients was performed. All the patients were treated with urokinase perfusion through the ophthalmology artery within the first 6 hours after central retinal artery occlusion attack. Conventional treatments including intra-ocular pressure decreasing, microcirculation improvement, neuroprotection and antiplatelet aggregation were conducted. The visual acuity (with International Snellen Chart) and field of vision were detected after thrombolysis. The complications and adverse events were observed. Results: Recanalization was found in 71% of patients. The visual acuity improvement was greater in the recanalization group (n=35) than in the non-recanalization group (n=14). The averaged visual acuity was 0.15±0.02, 0.25±0.03 and 0.4±0.05 after 2, 28 days and 6 months, respectively. Of the patients, 24.5% regained >0.6 of visual acuity, and the visual field deficit was less than 30% in 34.7% of patients after 28 days. Six months later, 36.7% patients regained visual acuity of >0.6, and the field deficit was less than 30% in 44.9% of patients. The difference between visual acuity in recanalization (0.6±0.04) and non-recanalization (0.002±0.0012) patients after 6 months after thrombolysis was significant (p>0.05). Conclusions: Intra-arterial thrombolysis could obviously improve the short- and long-term visual function for patients with acute central retinal artery occlusion within 6 hours of symptom onset.

A new model of reversible superior sagittal sinus thrombosis in rats.

To investigate the characteristics of the thrombus at different time points after thrombosis of the intracranial venous sinus, we have developed a new reversible superior sagittal sinus (SSS) model in rats. In this new model, thrombosis was induced by slow injections of the thrombogenic agent into the SSS using a microcatheter. The success of SSS thrombosis was confirmed by magnetic resonance images (MRI), magnetic resonance venographs (MRV), and electron microscopy. T2-weighted MRI and MRV were performed every week for 4 weeks to investigate the process of SSS occlusion. We also examined thrombus formation and the surrounding tissue pathology, as well as endothelial cell injury following SSS occlusion. SSS occlusion occurred at the beginning of the injection of the partial thromboplastin time reagent, and the occluded SSS reopened at the beginning of the second week. MRI images revealed that T2 signals were detected in the parieto-occipital lobes 24 h after SSS thrombosis and disappeared at the end of week two. During week two, the rate of thrombus organization was evident and increased significantly in week three. Thrombus calcification was detected in week three and increased significantly in week four. Electron microscopy examination showed the damaged endothelial cell detected at week three following SSS thrombosis. All of these findings suggest that this reversible SSS thrombosis model is feasible and reproducible. The occlusion state can be maintained for at least 4 weeks, providing an opportunity to study the mechanisms of SSS thrombosis.