Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis.

Background And Purpose: Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing.

Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course.

Objective: Cranial dural arteriovenous fistulae (dAVF) with cortical venous drainage (CVD) (Borden Types 2 and 3) are reported to carry a 15% annual risk of intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND). The purpose of this study was to compare the clinical course of Type 2 and 3 dAVFs that present with ICH or NHND with those that do not.

Methods: Twenty-eight patients with Type 2 or 3 dAVFs were retrospectively evaluated.

The diagnosis and management of supraaortic arterial dissections.

Purpose Of Review: To review recent advances in understanding supraaortic arterial dissections and their diagnosis and management.

Recent Findings: Dissection of the supraaortic arteries, including the extracranial carotid and vertebral arteries and intracranial arteries, is increasingly identified as an important cause of stroke and subarachnoid hemorrhage. The most common cause likely involves minor trauma with preexisting arteriopathy.

Near-complete resolution of angiographic cerebral vasospasm after extreme elevation of mean arterial pressure: case report.

Background: Cerebral vasospasm is a widespread and potentially treatable complication after aneurysmal SAH. Aggressive treatment often includes hemodynamic augmentation, although the exact mechanism by which such therapy leads to improved cerebral blood flow and reduced neurologic deficits is incompletely established. This case report is only the second to provide compelling evidence that hypertension can lead to direct dilation of vasospastic arteries, thereby providing valuable insight into its potential mechanism.

Spontaneous isolated convexity subarachnoid hemorrhage: presentation, radiological findings, differential diagnosis, and clinical course.

Object: The clinical characteristics and overall outcome in patients with spontaneous isolated convexity subarachnoid hemorrhage (SAH) are not well described in the literature. The purpose of this study was to examine the mode of presentation, common origins, radiographic findings, and clinical course in a large case series of such patients.

Methods: A retrospective single-center chart review of all patients in whom nontraumatic primary convexity SAH was diagnosed between 2002 and 2007 was performed.

Moyamoya phenomenon secondary to intracranial atherosclerotic disease: diagnosis by 3T magnetic resonance imaging.

Moyamoya phenomenon occurs in response to an occlusive vasculopathy affecting the distal internal carotid artery and its proximal branches. The nature of the occlusive vasculopathy is unknown in most patients. We present a patient in whom 3T magnetic resonance imaging was used to examine the arterial wall at the site of occlusion in a patient with unilateral moyamoya phenomenon.

Acute stroke imaging research roadmap.

The recent "Advanced Neuroimaging for Acute Stroke Treatment" meeting on September 7 and 8, 2007 in Washington DC, brought together stroke neurologists, neuroradiologists, emergency physicians, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute of Biomedical Imaging and Bioengineering (NIBIB), industry representatives, and members of the US Food and Drug Administration (FDA) to discuss the role of advanced neuroimaging in acute stroke treatment. The goals of the meeting were to assess state-of-the-art practice in terms of acute stroke imaging research and to propose specific recommendations regarding: (1) the standardization of perfusion and penumbral imaging techniques, (2) the validation of the accuracy and clinical utility of imaging markers of the ischemic penumbra, (3) the validation of imaging biomarkers relevant to clinical outcomes, and (4) the creation of a central repository to achieve these goals. The present article summarizes these recommendations and examines practical steps to achieve them.

Acute stroke imaging research roadmap.

The recent "Advanced Neuroimaging for Acute Stroke Treatment" meeting on September 7 and 8, 2007 in Washington DC, brought together stroke neurologists, neuroradiologists, emergency physicians, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute of Biomedical Imaging and Bioengineering (NIBIB), industry representatives, and members of the US Food and Drug Administration (FDA) to discuss the role of advanced neuroimaging in acute stroke treatment. The goals of the meeting were to assess state-of-the-art practice in terms of acute stroke imaging research and to propose specific recommendations regarding: (1) the standardization of perfusion and penumbral imaging techniques, (2) the validation of the accuracy and clinical utility of imaging markers of the ischemic penumbra, (3) the validation of imaging biomarkers relevant to clinical outcomes, and (4) the creation of a central repository to achieve these goals. The present article summarizes these recommendations and examines practical steps to achieve them.

Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level.

Background: Vertebrobasilar insufficiency caused by head rotation is an uncommon event. The mechanism is obstruction of the vertebral artery resulting in flow limitation or, less frequently, thromboembolism.

Case Description: A 41-year-old male developed dizziness and light-headedness during chiropractic manipulation when his head was turned to the extreme right position.

Endovascular treatment of vertebral artery-origin and innominate/subclavian disease: indications and technique.

Approximately 20% to 40% of patients who have cerebral vascular disease have a vertebral artery-origin stenosis. Atherosclerotic lesions of vertebral arety origin are a potential cause of posterior circulation ischemia, which can be disabling or deadly. Endovascular treatment of vertebral artery-origin and innominate/subclavian artery stenosis has changed in the last 15 years.

Technique for intracranial balloon and stent-assisted angioplasty for atherosclerotic stenosis.

Dilation of stenoses of the major intracranial arteries is now technically possible in many cases. Using proper precautions, most procedures can be performed without complications today, but the safety margin will likely be improved with refinement of current devices and the introduction of new devices made specifically for this indication. Early experience with these techniques is promising for lowering the risk for recurrent ischemic events in patients who have symptomatic intracranial arterial stenosis refractory to medical therapy.

Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial.

Atherosclerotic disease of the major intracranial arteries is a frequent cause of stroke. In addition, many patients who have symptomatic intracranial stenosis are at very high risk for recurrent stroke. Preliminary studies suggest that angioplasty and stenting may reduce the risk of stroke in patients who have severe stenosis of intracranial arteries.

Techniques of carotid angioplasty and stenting.

Carotid angioplasty and stenting (CAS) is an alternative technique to restore a normal lumen for patients who are at high risk for adverse effects with carotid endarterectomy (CEA). CAS has been shown to be of benefit to several groups of patients who have carotid disease and who ordinarily are excluded from many CEA trials. Government payors have approved embolic protection devices (EPDs) and stents for the now reimbursable procedure.

Mechanisms of ischemic stroke secondary to large artery atherosclerotic disease.

Atherosclerotic occlusive disease of the cervical and intracranial arteries leads to ischemic stroke through two separate, but interrelated, mechanisms: local thrombosis or embolism from atherosclerotic plaque, and hemodynamic failure (low flow). In this article, the author discusses the evidence linking these two mechanisms with cerebral ischemia, and the evidence for the synergistic effects of thromboembolism and impaired hemodynamics. An understanding of these two mechanisms is important because these mechanisms provide the rationale for revascularization for patients who have atherosclerotic stenosis or occlusion.

Carotid angioplasty and stenting in the elderly.

Introduction: To investigate the technical success rate as well as the procedural and mid-term complication rates of carotid angioplasty and stenting in elderly patients, a group excluded from large randomized endarterectomy trials given their perceived high surgical risk.

Methods: Of 200 consecutive carotid angioplasty and/or stenting procedures performed between March 1996 and March 2005, 21 procedures were performed without cerebral protection devices in 20 patients over the age of 79 years (mean age: 83 years, 12 men, eight women). These patients' medical records were retrospectively reviewed for vascular imaging reports and available clinical follow-up.

Patterns of infarction in hemodynamic failure.

Background And Purpose: The mechanism of stroke in patients with atherosclerotic occlusive disease and hemodynamic failure may be primarily hemodynamic or a combination of hemodynamic and embolic factors. The purpose of this study was to investigate the clinical and imaging features of stroke in these patients.

Methods: Eleven patients with complete atherosclerotic carotid artery occlusion and increased oxygen extraction fraction measured in the hemisphere distal to the occlusion developed an ischemic stroke during the observation phase of a prospective study of cerebral hemodynamics and stroke risk.

Mycotic pseudoaneurysm of the internal maxillary artery: case report and review of the literature.

Pseudoaneurysms of the internal maxillary artery are rare entities that are most commonly caused by trauma. Herein we report a novel case of an internal maxillary artery pseudoaneurysm of infectious etiology and discuss the diagnosis and treatment of this disease.

No effect of low-dose statins treatment on cerebral blood flow in humans with atherosclerotic cerebrovascular disease.

Animal studies have suggested that the reduction in stroke risk observed with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) therapy is owing to an increase in basal cerebral blood flow (CBF). The purpose of the study was to determine if statin therapy was associated with increased CBF in humans with cerebrovascular atherosclerotic disease. Quantitative measurements of CBF were obtained on study entry in 97 patients with carotid artery occlusion enrolled in a prospective study of cerebral hemodynamics and stroke risk.

Carotid stenting for asymptomatic carotid stenosis: trial it.

Angioplasty and stenting should not be performed for patients with asymptomatic atherosclerotic carotid bifurcation stenosis, except in the context of randomized clinical trials. Surgical carotid endarterectomy (CEA) has been proven effective over medical therapy in select asymptomatic patient populations. The benefit in these patients is small and easily overcome by procedural complication rates over 3%, owing to the relatively low risk for stroke on medical therapy.

Carotid angioplasty and stent placement for restenosis after endarterectomy.

Introduction: Recurrent carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of carotid angioplasty and stenting for recurrent stenosis.

Methods: Of 248 consecutive carotid angioplasty and/or stenting procedures performed at our institution between March 1996 and November 2005, 83 procedures for recurrent stenosis following endarterectomy were performed in 75 patients (mean age 68 years; 43 men, 32 women) without cerebral protection devices.

Neuroendovascular magnetic navigation: clinical experience in ten patients.

Introduction: The magnetic navigation system consists of an externally generated magnetic field that is used to control and steer a magnetically tipped microguidewire. The goal of this study was to demonstrate that the use of the magnetic navigation system and its magnetic microguidewire is feasible and safe in all types of neuroendovascular procedures.

Methods: A magnetic navigation system is an interventional workstation that combines a biplanar fluoroscopy system with a computer-controlled magnetic field generator to provide both visualization and control of a magnetically activated endovascular microguidewire.

Positron Emission Tomography Imaging of Cerebral Ischemia.

Positron emission tomography (PET) uniquely allows the in vivo regional measurement of several important physiologic parameters in living humans, including cerebral blood flow and oxygen metabolism. PET studies have advanced our understanding of normal human brain physiology and, as detailed in this article, our understanding of human cerebrovascular pathophysiology. This article focuses on knowledge gained from PET regarding acute ischemic stroke and chronic oligemia from arterial occlusive disease.

Endovascular treatment of the vertebral artery origin in patients with symptoms of vertebrobasilar ischemia.

Introduction: We report our experience with the endovascular treatment of the vertebral artery origin in patients presenting with symptomatic vertebrobasilar ischemia and compare our results with those reported in the literature.

Methods: In 25 patients, 28 procedures were performed. Patients presented with posterior circulation ischemic symptoms despite optimal medical therapy with antiplatelet drugs and had a digital subtraction angiogram demonstrating stenosis of the origin of the vertebral artery greater than 50%.

Etiology of strokes in children with sickle cell anemia.

The most devastating complication of sickle cell anemia is cerebral infarction, affecting approximately 30% of all individuals with sickle cell anemia. Despite being one of the most common causes of stroke in infants and children, the mechanism of cerebral infarction in this population has not been extensively studied and is poorly understood. Multiple, synergistic factors are important in the pathogenesis of stroke including the hemodynamic effects of cerebral arterial occlusive disease, viscosity, chronic and acute anemia and acute medical events.