Wengui Yu

Long-term outcome of endovascular stenting for symptomatic basilar artery stenosis

Eighteen patients underwent stenting for symptomatic basilar artery stenosis. There were three major periprocedural complications (16.7%) without fatality. At a mean 26.7 ± 12.1-month follow-up, 15 patients (83.3%) had an excellent long-term outcome. Only one patient (5.6%) had moderate disability from recurrent stroke, and two patients died of medical illness at 30 and 36 months after stenting. In this uncontrolled study, stenting appeared to be effective in reducing stroke risk and death and worthy of further scrupulous trial.

Outcome of Patients With ≥70% Symptomatic Intracranial Stenosis After Wingspan Stenting

Background and Purpose— There were limited data on the long-term outcome of patients with symptomatic intracranial atherosclerotic stenosis ≥70% after Wingspan stenting. Using our Wingspan cohort data and the data from the Warfarin and Aspirin for Symptomatic Intracranial Atherosclerotic Disease (WASID) as a historical control, we tested the hypothesis that stenting provided no benefit over antithrombotic therapy alone for these high-risk patients. Methods— Between January 2007 and February 2009, 100 consecutive patients with intracranial atherosclerotic stenosis ≥70% and symptoms within 90 days were enrolled into this prospective single-center Wingspan cohort study and followed up until the end of February 2010. Stenosis was measured per the WASID criteria. One-year risk of primary end point (any stroke or death within 30 days and ipsilateral ischemic stroke afterward) was compared with that of ipsilateral ischemic stroke in the WASID patients with ≥70% stenosis. Results— The stent placement success rate was 99%. All patients but 1 had clinical follow-up of ≥12 months. During a mean follow-up of 1.8 years, 9 patients developed primary end point events (5 within 30 days and 4 afterward). The 1-year risk of the outcome events was lower than that in similar WASID patients: 7.3% (95% CI, 2.0% to 12.5%) versus 18% (95% CI, 13% to 24%; P<0.05). Conclusions— The clinical outcome of Wingspan stenting for high-risk intracranial atherosclerotic stenosis patients in this high-volume center study compares favorably with that of antithrombotic therapy alone. A randomized trial comparing medical therapy alone with medical therapy plus Wingspan stenting, conducted at high-volume centers, is needed to confirm the stenting benefit.

Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients

Intracranial hemorrhage (ICH) is a common problem encountered by neurosurgeons. Patient outcomes are influenced by hematoma size, growth, location, and the timing of evacuation, when indicated. Patients may have abnormal coagulation due to pharmacological anticoagulation or coagulopathy due to underlying systemic disease or blood transfusions. Strategies to reestablish the integrity of the clotting cascade and platelet function assume a familiarity with these processes. As patients are increasingly treated with anticoagulants and antiplatelet agents, it is essential that the physicians who care for patients with ICH understand these pathways and recognize how they can be manipulated to restore hemostasis.

Endovascular embolectomy of acute basilar artery occlusion

Acute basilar artery occlusion has a mortality rate approaching 90%. The authors describe a case of acute basilar artery occlusion managed successfully with endovascular embolectomy. A 31-year-old man sought treatment for confusion, dysarthria, and right-sided weakness. He soon became unresponsive and was found to have a vertebral artery dissection and an associated basilar artery embolism. The dissection was managed with endovascular stenting, and the basilar artery embolus was removed with a clot retriever at 7 hours. The patient recovered without neurologic deficit.

Hypoplasia or Occlusion of the Ipsilateral Cranial Venous Drainage Is Associated With Early Fatal Edema of Middle Cerebral Artery Infarction

Background and Purpose— Thrombosis of the cerebral venous sinus may cause venous congestion, cerebral edema, and infarction. The role of cerebrovenous disorders in arterial ischemic stroke is unknown. The objective of this study was to examine the contribution of ipsilateral cranial venous abnormalities to the development of cerebral edema in middle cerebral artery infarction. Methods— This is a retrospective study of consecutive patients with large middle cerebral artery infarction admitted to our neurocritical care unit from January 2007 to October 2008. Medical records, laboratory data, and imaging of cerebral edema and cranial venous sinuses were analyzed. Results— Of the 14 patients identified to have large middle cerebral artery infarction and images of cranial venous drainages, 5 (35.7%) had fatal edema with clinical signs of transtentorial herniation. Four of the 5 patients developed fatal edema within 48 hours of ictus and were found to have abnormal ipsilateral cranial venous drainage, including atresia of the transverse sinus (one), occlusion of the internal jugular vein (one), and hypoplasia of the transverse sinus and internal jugular vein (2). The fifth patient had symmetrical bilateral cranial venous drainages and fatal edema at Day 5. Of the 9 patients with nonmalignant middle cerebral artery infarction, all had ipsilateral dominant or symmetrical bilateral venous drainages. Conclusions— In this small case series, we demonstrated that only the patients with hypoplasia or occlusion of the ipsilateral cranial venous drainage developed early fatal edema after large middle cerebral artery infarction. Our results suggest a role of cranial venous outflow abnormalities in the development of brain edema after arterial ischemic stroke.

Endovascular Recanalization of Basilar Artery Occlusion 80 Days After Symptom Onset

Background and Purpose— Acute basilar artery occlusion portends high risk of stroke and death. Thrombolysis or endovascular therapy has been limited to patients who present within hours of symptom onset. Without recanalization, acute basilar artery occlusion almost always results in death or severe disability. Summary of Case— We report a case of basilar artery occlusion and successful endovascular recanalization 80 days after symptom onset. Conclusions— Endovascular therapy can be feasible and safe for symptomatic basilar artery occlusion at chronic stage.

High resolution MRI guided endovascular intervention of basilar artery disease

Background and aim High resolution MR imaging (HRMRI) has been used to study intracranial atherosclerotic plaques. How HRMRI guided our decision making process in endovascular intervention of basilar artery (BA) atherosclerotic disease is reported. Methods 3 patients with symptomatic BA atherosclerotic disease underwent BA wall HRMRI under a 3 T MR scanner. Endovascular intervention was then performed utilizing HRMRI findings to guide therapy and to aid in planning the intervention. Results HRMRI clearly identified the eccentric atherosclerotic plaque at the opposite side of the adjacent right anterior inferior cerebellar artery in one patient and left posterior cerebral artery in one patient, and eccentric atherosclerotic plaque protruding BA lumen at the opposite side of the adjacent right anterior inferior cerebellar artery in the remaining patient. The BA stenosis was stented without compromise of the adjacent branch arteries in the three patients. Conclusion HRMRI may be used to delineate the eccentric atherosclerotic plaque and the ostia of the major side branches of BA. The HRMRI findings seem helpful in guiding BA stenting with reduced complication risk.

Carotid artery dissection and middle cerebral artery stroke following methamphetamine use.

Methamphetamine use may be associated with increased risk of stroke in young adults. We describe two cases of carotid artery dissection and ispilateral middle cerebral artery (MCA) stroke following methamphetamine use. ### Patient 1. A 36-year-old right-handed woman had sudden onset of speech difficulty and right-sided weakness while eating lunch. She presented to the emergency department within 30 minutes. Her medical history was significant for migraine and oral contraceptive and methamphetamine use. She was smoking methamphetamine with some left neck pain over the preceding two nights. Her initial examination was remarkable for global aphasia, left gaze preference, and right hemiplegia without Horner syndrome. The NIH Stroke Scale (NIHSS) score was 21. The initial head CT was unremarkable. IV tissue plasminogen activator (tPA) was started within 80 minutes of symptom onset. She improved significantly with only moderate expressive aphasia and mild right hemiparesis 8 hours after tPA therapy. A follow-up diffusion-weighted MRI of the brain showed a small infarct in the …

Wingspan experience at Beijing Tiantan Hospital: new insights into the mechanisms of procedural complication from viewing intraoperative transient ischemic attacks during awake stenting for vertebrobasilar stenosis

Background and aim Intracranial vertebrobasilar artery (VBA) stenosis portends a stroke and death rate of 8.5–22.8% annually despite medical therapy. Stenting has emerged as a treatment option but also carries substantial risk. Awake stenting under local anesthesia to minimize major procedural complication was investigated. Methods Between January 2007 and December 2008, 43 of 46 consecutive patients with severe symptomatic intracranial VBA stenosis underwent elective angioplasty assisted with self-expanding Wingspan stent under local anesthesia at our institute. All data were collected prospectively. Results All 43 patients tolerated the stenting procedure under local anesthesia well. Forty-two patients (97.7%) were stented successfully. Within 30 days, there were three periprocedural strokes, including thromboembolic infarct, pontine perforator infarct and intracranial hemorrhage, without fatality. In addition, five patients had intraoperative brainstem transient ischemic attacks (TIAs) seconds after the deployment of the stent delivery system across the tortuous VBA. The symptoms and signs included impaired consciousness (n=5), dysarthria (n=3), convulsion (n=2), conjugate horizontal gaze palsy (n=2), nystagmus (n=2) and pinpoint pupils (n=1). There was angiographic evidence of VBA straightening without thromboembolism. The TIAs resolved within minutes of prompt removal of the delivery catheter. Conclusions VBA stenting under local anesthesia is feasible with a 7% periprocedural stroke risk. Awake stenting allows timely detection of intraoperative TIAs. The mechanism of intraoperative TIA appears to be stent delivery system induced VBA straightening and distortion of its vascular tree. A devastating stroke may ensue if the TIA is not detected and distortion of VBA perforators is not reversed promptly.

Current management of spontaneous intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140–150 mEq/L for 7–10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.