Purpose Intracranial dissections (ICDs) of the circle of Willis are recognized as important causes of both ischemic and hemorrhagic cerebrovascular disease. Although endovascular surgery (ES) of ICD has been increasingly reported, large series safety and efficacy data remain limited for establishing evidence basis of practice. Owing to our large scale cumulative experience with intracranial stent-assisted techniques, we reviewed standard angiographic & clinical end-points to assess safety & efficacy of stent-assisted reconstruction (SAR) ES of ICD.
Materials and Methods Consecutive intention-to-treat (ITT) cases of ICD were identified by a prospective database; retrospective analysis revealed 164 consecutive cases of ICD treated by SAR techniques (e.g, stent reconstruction only, stent assisted coiling) from 2003 to 2010. Standardized angiographic & clinical endpoints were defined as: 1: (i). peri-operative technical & angiographic outcomes, (ii)death & neurologic morbidity within 24 h and 30 days, and 2: (i) >30 day cumulative neurologic morbidity & mortality, (ii)follow-up angiographic outcome, (iii) retreatment.
Results The ITT rate was 100%; patient demographics: 92F:72M, mean age=48.5 years. Anatomic distribution: 79/164 (48%) anterior and 85/164 (52%) posterior circulation. Lesion characteristics: 103/164 (62%) had associated pseudo-aneurysm (ψAn), 78/164 (47.5%) stenosis, 25/164 (15.2%) intimal flap, 4/164 (%) occlusion, 10/164 (%) with thrombi, and 12/162 with fusiform dilatation. Presentation was ischemic in 77/164 (47%), hemorrhagic in 33/164 (20%), headache in 20/164 (12.2%), neck pain in 12/164 (7.3%), miscellaneous in 15/164 (9.1%), and incidental in 7/164 (4.3%). Stent reconstruction only was performed in 114/164 (70%), stent-assisted coiling in 30/164 (18.3%), SAR with balloon angioplasty in 17/164 (10.4%), and thrombolysis followed by SAR in 3/164 (1.8%). Stents utilized: 144 Neuroform (NF), 108 Enterprises (E), 23 combined NF+E, 19 Wingspans (W), and 6 W combined with either NF or E. More than one stent was used in 88/164 (53.7%), and a single stent in 76/164 (46.3%). Follow-up DSA in 95 cases showed healed dissection in 76, unchanged or increased filling of pseudoaneurysm in 6 (all requiring retreatment), decreasing filling of pseudoaneurysm in 3, clots in 2, occluded stent(s) in 2, and in-stent stenosis >50% in 2. In the remaining 70 cases with no DSA, CTA or MRA were available in 54, which showed healed dissection in 48, decreasing in 3 and increasing in 3. Retreatment was performed in 19/164 (11.6%). There were 18/164 (11%) technical complications, although clinically significant attributable periprocedural (<24 h) morbidity occurred in only 3/164 (1.8%). Cumulative 30-day neurologic morbidity was 7/164 (4.3%), and mortality (from rebleed) in only 1/164 (0.6%). Recurrent stroke after 30 days occurred in 4/163 (2.5%).
Conclusions ES of ICD using SAR appears quite safe & effective with acceptable rates of treatment failure and need for retreatment. The most commonly encountered associated lesion was ψAn, which is effectively managed by SAR without and occasionally with coiling.
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