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Aging and disease    2017, Vol. 8 Issue (2) : 196-202     DOI: 10.14336/AD.2016.0807
Review |
Spanning from the West to East: An Updated Review on Endovascular Treatment of Intracranial Atherosclerotic Disease
Hussain Mohammed1, Datta Neil1, Cheng Zhe2, Dornbos David3, Bashir Asif4, Sultan Ibrahim5, Mehta Tapan1, Shweikeh Faris6, Mazaris Paul1, Lee Nora1, Nouh Amre1, Geng Xiaokun2,7,*, Ding Yuchuan7,*
1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
2Department of Neurology, Luhe Hospital, Capital Medical University, Beijing 101149, China
3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, OH 43210, USA
4Department of Neurosurgery, Seton Hall University, South Orange, NJ 07079, USA
5Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
6Department of Surgery, University of Arizona, Tucson, AZ 85724, USA
7Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48236, USA
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Ischemic stroke is a major cause of morbidity and mortality, incurring significant cost. Intracranial atherosclerotic disease (ICAD) accounts for 10-15% of ischemic stroke in Western societies, but is an underlying pathology in up to 54% of ischemic strokes in Asian populations. ICAD has largely been treated with medical management, although a few studies have examined outcomes following endovascular treatment. Our objective was to summarize the major trials that have been performed thus far in regard to the endovascular treatment of ICAD and to provide direction for future management of this disease process. Systematic review of the literature from 1966 to 2015, was conducted in regard to intracranial angioplasty and stenting. Studies were analyzed from PubMed, American Heart Association and Society of Neurointerventional Surgery databases. SAMMPRIS and VISSIT are the only randomized controlled trials from which Western guidelines of intracranial stenting have been derived, which have displayed the superiority of medical management. However, pooled reviews of smaller studies and other nonrandomized trials have shown better outcomes with endovascular therapy in select patient subsets, such as intracranial vertebrobasilar stenosis or in the presence of robust collaterals. Suboptimal cases, including longer lesions, bifurcations and significant tortuosity tend to fair better with medical management. Medical management has been shown to be more efficacious with less adverse outcomes than endovascular therapy. However, the majority of studies on endovascular management included a diverse patient population without ideal selection criteria, resulting in higher adverse outcomes. Population analyses and selective utilization of endovascular therapy have shown that the treatment may be superior to other management in select patients.

Keywords ischemic stroke      randomized controlled trials      intracranial stenting      medical management in ICAD     
Corresponding Authors: Geng Xiaokun,Ding Yuchuan   
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These authors contributed equally

Issue Date: 01 April 2017
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Hussain Mohammed
Datta Neil
Cheng Zhe
Dornbos David
Bashir Asif
Sultan Ibrahim
Mehta Tapan
Shweikeh Faris
Mazaris Paul
Lee Nora
Nouh Amre
Geng Xiaokun
Ding Yuchuan
Cite this article:   
Hussain Mohammed,Datta Neil,Cheng Zhe, et al. Spanning from the West to East: An Updated Review on Endovascular Treatment of Intracranial Atherosclerotic Disease[J]. Aging and disease, 2017, 8(2): 196-202.
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Medical ManagementEndovascular Therapy
- Severe stenosis (70-99%)
- Multicenter, use of Wingspan stent
- Medical management: 14.9% risk of stroke/death at 32 mo
- Endovascular: 23.9%
Abuzinadah et. al, 2014 (meta-analysis)
- Patients with vertebro-basilar stenosis
- Medical: stroke/death in 14.8/100-patient
- Endovascular: 8.9/100-patient years
- Multicenter, balloon-assisted stent
- Medical: 15.1% stroke risk at 1 year
- Endovascular: 34.5%
Feng et. al, 2015 (retrospective review)
- Single center, balloon-assisted Enterprise stent
- 100% technical success rate; 9.1% peri-opertaive stroke risk
Jiang et. al, 2011 (retrospective review)
- Single center, Wingspan stent
- 5% stroke/death risk at 30-days
Miao et. al, 2015 (prospective cohort)
- Technical success rate 96.3%
- 4.4% stroke/death risk at 30-days
Table 1  Comparison of major studies promoting medical management or endovascular therapy.
[1] Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. (2015). Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation, 131: e29-322
[2] Sacco RL, Kargman DE, Gu Q, Zamanillo MC (1995). Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke, 26: 14-20
[3] Qureshi AI, Caplan LR (2014). Intracranial atherosclerosis. Lancet, 383: 984-998
[4] Holmstedt CA, Turan TN, Chimowitz MI (2013). Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment. The Lancet. Neurology, 12: 1106-1114
[5] Bang OY (2014). Intracranial atherosclerosis: current understanding and perspectives. J Stroke, 16: 27-35
[6] Arenillas J (2015). Intracranial atherosclerosis and inflammation: Lessons from the East and the West. Brain Circulation, 1: 47-52
[7] Hass WK, Fields WS, North RR, Kircheff II, Chase NE, Bauer RB (1968). Joint study of extracranial arterial occlusion. II. Arteriography, techniques, sites, and complications. JAMA, 203: 961-968
[8] Liu LH, Caplan LR, Kwan E, Beldon JR, Ke DS, Nien CK (1996). Racial differences in ischemic cerebrovascular disease: clinical and magnetic resonance angiographic correlations of white and Asian patients. J Stroke Cerebrovasc Dis, 6: 79-84
[9] Gorelick PB, Caplan LR, Hier DB, Patel D, Langenberg P, Pessin MS, et al. (1985). Racial differences in the distribution of posterior circulation occlusive disease. Stroke, 16: 785-790
[10] (1995). Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA, 273: 1421-1428
[11] Dion JE, Gates PC, Fox AJ, Barnett HJ, Blom RJ (1987). Clinical events following neuroangiography: a prospective study. Stroke, 18: 997-1004
[12] Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, et al. (2005). Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med, 352: 1305-1316
[13] Kasner SE, Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, et al. (2006). Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation, 113: 555-563
[14] Derdeyn CP, Chimowitz MI (2007). Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am, 17: 355-363, viii-ix
[15] Xunming J (2015). Forward thinking in stroke treatment: Advances in cerebrovascular reperfusion and neurorehabilitation. Brain Circulation, 1: 1-2
[16] Connors JJ3rd, Wojak JC (1999). Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg, 91: 415-423
[17] Marks MP, Wojak JC, Al-Ali F, Jayaraman M, Marcellus ML, Connors JJ, et al. (2006). Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke, 37: 1016-1020
[18] Al-Ali F, Cree T, Duan L, Hall S, Jefferson A, Louis S, et al. (2011). How effective is endovascular intracranial revascularization in stroke prevention? Results from Borgess Medical Center Intracranial Revascularization Registry. AJNR Am J Neuroradiol, 32: 1227-1231
[19] Siddiq F, Memon MZ, Vazquez G, Safdar A, Qureshi AI (2009). Comparison between primary angioplasty and stent placement for symptomatic intracranial atherosclerotic disease: meta-analysis of case series. Neurosurgery, 65: 1024-1033; discussion 1033-1024
[20] Investigators SS (2004). Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke, 35: 1388-1392
[21] Bose A, Hartmann M, Henkes H, Liu HM, Teng MM, Szikora I, et al. (2007). A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke, 38: 1531-1537
[22] Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, et al. (2007). US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke, 38: 881-887
[23] Zaidat OO, Klucznik R, Alexander MJ, Chaloupka J, Lutsep H, Barnwell S, et al. (2008). The NIH registry on use of the Wingspan stent for symptomatic 70-99% intracranial arterial stenosis. Neurology, 70: 1518-1524
[24] Carcora Y, Hussain M, Geng X, Ding Y (2015). A review of current clinical studies leading to improved outcomes in patients treated with newer-generation thrombectomy devices. Brain Circulation, 1: 9-13
[25] Higashida RT, Tsai FY, Halbach VV, Dowd CF, Smith T, Fraser K, et al. (1993). Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries. J Neurosurg, 78: 192-198
[26] Gress DR, Smith WS, Dowd CF, Van Halbach V, Finley RJ, Higashida RT (2002). Angioplasty for intracranial symptomatic vertebrobasilar ischemia. Neurosurgery, 51: 23-27; discussion 27-29
[27] Chimowitz MI, Kokkinos J, Strong J, Brown MB, Levine SR, Silliman S, et al. (1995). The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology, 45: 1488-1493
[28] Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. (2011). Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med, 365: 993-1003
[29] Chimowitz MI, Derdeyn CP (2015). Endovascular therapy for atherosclerotic intracranial arterial stenosis: back to the drawing board. JAMA, 313: 1219-1220
[30] Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. (2014). Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet, 383: 333-341
[31] Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45: 2160-2236
[32] Turan TN, Derdeyn CP, Fiorella D, Chimowitz MI (2009). Treatment of atherosclerotic intracranial arterial stenosis. Stroke, 40: 2257-2261
[33] Morris P (1997). Practical neuroangiography (Vol. 47). Chapter 3 Baltimore: Williams & Wilkins.
[34] Hussain MS, Fraser JF, Abruzzo T, Blackham KA, Bulsara KR, Derdeyn CP, et al. (2012). Standard of practice: endovascular treatment of intracranial atherosclerosis. J Neurointerv Surg, 4: 397-406
[35] Teleb MS, Asif K, Castonguay AC, Zaidat OO (2014). Endovascular management of intracranial atherosclerosis. Neurosurg Clin N Am, 25: 593-605
[36] Derdeyn CP, Fiorella D, Lynn MJ, Rumboldt Z, Cloft HJ, Gibson D, et al. (2013). Mechanisms of stroke after intracranial angioplasty and stenting in the SAMMPRIS trial. Neurosurgery, 72: 777-795; discussion 795
[37] Fiorella D, Derdeyn CP, Lynn MJ, Barnwell SL, Hoh BL, Levy EI, et al. (2012). Detailed analysis of periprocedural strokes in patients undergoing intracranial stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS). Stroke, 43: 2682-2688
[38] Miao Z, Song L, Liebeskind DS, Liu L, Ma N, Wang Y, et al. (2015). Outcomes of tailored angioplasty and/or stenting for symptomatic intracranial atherosclerosis: a prospective cohort study after SAMMPRIS. Journal of neurointerventional surgery, 7: 331-335
[39] Abuzinadah AR, Alanazy MH, Almekhlafi MA, Duan Y, Zhu H, Mazighi M, et al. (2016). Stroke recurrence rates among patients with symptomatic intracranial vertebrobasilar stenoses: systematic review and meta-analysis. J Neurointerv Surg, 8: 112-116
[40] Groschel K, Schnaudigel S, Pilgram SM, Wasser K, Kastrup A (2009). A systematic review on outcome after stenting for intracranial atherosclerosis. Stroke, 40: e340-347
[41] Leung TW, Kwon SU, Wong KS (2006). Management of patients with symptomatic intracranial atherosclerosis. Int J Stroke, 1: 20-25
[42] Cruz-Flores S, Diamond AL (2006). Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev: CD004133
[43] Short JL, Majid A, Hussain SI (2011). Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol, 1: 160
[44] Wong LK (2006). Global burden of intracranial atherosclerosis. Int J Stroke, 1: 158-159
[45] Wu Z, Yao C, Zhao D, Wu G, Wang W, Liu J, et al. (2001). Sino-MONICA project: a collaborative study on trends and determinants in cardiovascular diseases in China, Part i: morbidity and mortality monitoring. Circulation, 103: 462-468
[46] Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B (1996). Race and sex differences in the distribution of cerebral atherosclerosis. Stroke, 27: 1974-1980
[47] Yoon W, Seo JJ, Cho KH, Kim MK, Kim BC, Park MS, et al. (2005). Symptomatic middle cerebral artery stenosis treated with intracranial angioplasty: experience in 32 patients. Radiology, 237: 620-626
[48] Yu SC, Leung TW, Lee KT, Wong LK (2014). Angioplasty and stenting of intracranial atherosclerosis with the Wingspan system: 1-year clinical and radiological outcome in a single Asian center. J Neurointerv Surg, 6: 96-102
[49] Shin YS, Kim BM, Suh SH, Jeon P, Kim DJ, Kim DI, et al. (2013). Wingspan stenting for intracranial atherosclerotic stenosis: clinical outcomes and risk factors for in-stent restenosis. Neurosurgery, 72: 596-604; discussion 604
[50] Zhao LB, Park S, Lee D, Lee DH, Suh DC (2012). Mechanism of procedural failure related to wingspan. Neurointervention, 7: 102-108
[51] Jiang L, Ling F, Wang B, Miao Z (2011). Insight into the periprocedural embolic events of internal carotid artery angioplasty. A report of four cases and literature review. Interv Neuroradiol, 17: 452-458
[52] Feng Z, Duan G, Zhang P, Chen L, Xu Y, Hong B, et al. (2015). Enterprise stent for the treatment of symptomatic intracranial atherosclerotic stenosis: an initial experience of 44 patients. BMC Neurol, 15: 187
[53] Jiang WJ, Yu W, Du B, Gao F, Cui LY (2011). Outcome of patients with >/=70% symptomatic intracranial stenosis after Wingspan stenting. Stroke, 42: 1971-1975
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