Advances in Stroke 2005

Advances in Interventional Neuroradiology 2005

David Pelz, MD, FRCPC; Tommy Andersson, MD; Michael Soderman, MD, PhD;
Pedro Lylyk, MD; Makoto Negoro, MD

n the wake of the SAPPHIRE trial1 and subsequent

approval of carotid stenting (CAS) devices by the Food and
Drug Administration (FDA) in the United States, CAS is
poised to explode in the frequency of its application in North
America. Although the results of the Carotid Revascularization Stenting versus Endarterectomy Trial (CREST), the
largest randomized controlled trial comparing carotid endarterectomy to CAS, are years away, many practitioners in
multiple disciplines have already entered the competition for
patients and remuneration. Despite the absence of evidence to
support CAS over carotid endarterectomy2,3 and the need to
continue recruiting patients to CREST,4 cardiologists, vascular surgeons, neurologists, neurosurgeons, general interventional and neurointerventional radiologists are all vying to
treat carotid stenoses, many of which are 70% in severity,
and asymptomatic.2,5,6 Attempts are being made to establish
training, competency and credentialing standards for performance of CAS, and they vary widely between specialties.7,8,9
Computer simulations are playing a larger role in this
process10 and may help to address the mismatch between
training opportunities and interested practitioners. There have
been concerns about the SAPPHIRE trial11 and the incidence
of restenosis in previous case series.3,12 The techniques of
CAS are still variable, with some operators advocating the
use of cerebral protection devices,13 whereas others found
that distal emboli might be more common with their usage.14
Although abnormalities on diffusion-weighted MRI after
CAS are not uncommon (up to 30% of patients), most of
these are asymptomatic.15 Patient related risk factors might be
important determinants of complication rates after CAS, with
those presenting with hemispheric strokes at particularly high
risk.16 There may be a role for preoperative ultrasound in the
identification of friable plaque, which may be more likely to
generate distal emboli during CAS procedures.17

as 8.3%, with the annual risk of stroke in the territory of the treated
vessel between 3% to 5%.21 Balloons and stents are considerably
softer and more flexible than earlier cardiology devices, and a new
self-expanding stent specifically designed for intracranial use has
recently become available.18,19 This procedure, however, remains
hazardous with up to 50% of patients showing new, ipsilateral
ischemic lesions on diffusion-weighted MR images.22 Angioplasty
alone may be safer than the combination with stenting,21 and
drug-eluting stents, although showing promise in coronary and
canine vessels for the prevention of restenosis,18 are still not ready
for human cerebral arteries because of differing histology and
questions of drug neurotoxicity.

Acute Stroke Interventions

The limitations of intravenous (IV) and intra-arterial (IA) chemical thrombolysis for reperfusion in acute stroke are becoming
more apparent. The MERCI (Mechanical Embolus Removal in
Cerebral Ischemia) trial of a dedicated device for mechanical
embolectomy in stroke has been updated to include 141 patients
who presented within 8 hours of their acute event.23 A 48%
recanalization rate was obtained using this device, with a trend
toward improved neurological outcome at 90 days in these
patients, although symptomatic hemorrhages occurred in almost
28% of patients and overall mortality in the series was 44%. The
high mortality may have been attributable to the initial severity
of the strokes, the large number of basilar and internal carotid
terminus emboli, and the advanced age of the patients compared
with other series. Another series24 reported an 80% recanalization rate in 10 patients treated with this device, although the
mortality rate was still 50%. There is some evidence that a very
aggressive, multimodality approach using IV or IA GP IIb/IIIa
antagonists abciximab or tirofiban, IA recombinant tissue plasminogen activator or urokinase, and percutaneous angioplasty
and stenting may result in more favorable outcomes, with
promising results in small numbers of patients.25,26,27 Preliminary results suggest that endovascular ultrasound probes can
accelerate thrombolysis28; however, externally applied ultrasound combined with IV recombinant tissue plasminogen activator may increase the risk of hemorrhage.29 There are at least 3
commercial devices in development for selective, endovascular,
locally induced hypothermia to limit brain damage during

Intracranial Angioplasty and Stenting

for Atherosclerosis
As technology and experience evolve, this procedure is becoming
increasingly effective and safe for the treatment of intracranial
atherosclerotic disease, and guidelines are being developed for its
use.18,19 Although still performed relatively infrequently,20 the risks
of periprocedural stroke and death have been reported to be as low

Received December 2, 2005; accepted December 16, 2005.

From the University of Western Ontario (D.P.); the Karolinska Institute (T.A., M.S.), Stockholm, Sweden; and ENERI (P.L.), Buenos Aires, Argentina.
Department of Neurosurgery (M.N.), Fujita Health University, Toyoake, Japan.
Correspondence to David Pelz, Department of Diagnostic Radiology, University Hospital, University of Western Ontario, 339 Windermere Rd,
London, Ontario, Canada N6A 5A5. E-mail pelz@uwo.ca
(Stroke. 2006;37:309-311.)
2006 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

DOI: 10.1161/01.STR.0000201436.30248.ec

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Stroke

February 2006

chemical or mechanical procedures in acute stroke patients. In

vitro animal experiments have shown encouraging results.30

Aneurysms
A new self-expanding, closed-cell design nitinol stent, designed
for the endovascular treatment of wide-necked cerebral aneurysms,31 was recently introduced, featuring less permeability to
coil migration and the ability to recapture and reposition the stent
if necessary. Current and emerging therapies32 continue to be
analyzed, particularly regarding their durability. The International Subarachnoid Aneurysms Trial (ISAT) was updated to
present clinical outcomes at 1 year posttreatment.33 The early
survival advantage of endovascular related to surgical therapy
was maintained up to 7 years, with an absolute risk reduction of
7.4%. The endovascular group also had a lower incidence of
epilepsy, and a low incidence of rebleeding (0.2% per patientyear), but higher incidence of rebleeding than the surgical group.
Another analysis of 160 consecutive patients undergoing coil
treatment showed that 73% were independent at 18 months, with
an annual delayed rebleed risk of 0.45%.34 Almost 50% of
patients, however, experienced negative events, such as aneurysmal remnant increase, retreatment, rebleeding or death. Overall clinical outcome was related to the immediate postprocedural
angiographic result, which in turn was related to microcatheter
stability, aneurysm geometry and aneurysm neck diameter.
Follow-up of complex and wide-necked aneurysms treated with
stents and coils has shown good results with acceptable occlusion and complication rates.35,36

Arteriovenous Malformations
The natural history of brain arteriovenous malformations
(BAVMs) is still not well understood, and the decision to treat
remains complicated. Important factors are patient age, associated aneurysms, deep location and prior hemorrhage; however,
the risk of an unruptured BAVM may be lower than previously
thought.37,38 A randomized controlled trial of treatment versus
no treatment in this group may be of value.39 The results of
embolization with Onyx continue to improve and in some
centers are comparable to those of microsurgery for SpetzlerMartin grades 1 and 2 lesions.40 Advances in gene therapy may
lead to innovative interventions in the future.41

Vasospasm
Balloon angioplasty remains the mainstay of accepted treatment for
postsubarachnoid hemorrhage vasospasm when medical therapy
fails to reverse the deficits,42 and a combination of angioplasty with
IA nicardipine may represent a promising protocol.43 There is still a
need to develop a soft, flexible, dedicated balloon for angioplasty in
vasospasm, as currently used balloons are designed for other
applications, such as balloon remodeling during aneurysm coiling.
Various IA drugs aside from papaverine are now being used more
frequently, including nimodipine and verapamil.44 A new doubleballoon catheter device to obtain partial aortic obstruction has been
shown to increase cerebral blood flow in these patients without
inducing systemic hypertension.45 The quest to identify those
patients most likely to develop vasospasm continues, with a large
blood burden still representing the most consistent risk factor.46
Better understanding of the causes of vasospasm has led to promising preventative therapies, such as clazosentan47 and the statins
simvastatin and pravastatin.48 Transcranial duplex sonography re-

mains the most reliable imaging modality to identify middle

cerebral artery vasospasm,49 and perfusion CT and MRI are being
used more frequently to identify brain at risk for infarction from
vasospasm.50

Imaging
As noninvasive imaging and carotid stenting become more
popular, the precise measurement of atherosclerotic carotid
stenosis becomes more critical. Conventional digital subtraction angiography (DSA) is being replaced as the gold standard for carotid stenosis measurement by 3-dimensional
computed rotational angiography.51,52 DSA has long been
suspected of underestimating the disease burden, and
contrast-enhanced magnetic resonance angiography may actually correlate best with 3-dimensional computed rotational
angiography.52 DSA remains the gold standard for target
definition in radiosurgery of BAVMs.53

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KEY WORDS: aneurysm carotid arteries intracranial arteriovenous
malformations intracranial vasospasm stents