Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
View/Download PDF

Translate this page into:

Commentary
4 (
3
); 303-304

Commentary

Department of Medicine, Surgery and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy

Address for correspondence: Prof. Carlo Setacci, Department of Medicine, Surgery and Neuroscience,Vascular and Endovascular Surgery Unit, University of Siena, Viale Bracci 1, 53100, Siena, Italy. E-mail: setacci@unisi.it

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

We have read very carefully and with great interest the article titled “Endovascular treatment of acute ischemic stroke: A review.” It is without doubt an excellent review article on the endovascular treatment of acute ischemic stroke (AIS).[1]

As we know, AIS is a leading cause of death and disability in the developed world. For the patient, a stroke can be devastating, involving problems such as loss of mobility, independence, and communication, and comprehension skills, thus leading to huge costs in healthcare and loss of productivity.

Treatment of AIS is time-dependent, with the best outcomes resulting from the earliest interventions. Options for acute stroke treatment include those conditions that do not require interventional access, such as intravenous thrombolysis, and those that require intervention, such as intra-arterial loco-regional thrombolysis or endovascular artery revascularization.

Nowadays, for patients with AIS who present with serious neurological deficits associated with a high-grade stenosis of the internal carotid artery (ICA), despite maximal medical treatment, an effective intervention to improve their neurologic symptoms and clinical outcome has not yet been established; so, this paper could add more to our knowledge.

By the way, the paper does not focus at all on the possibility of an endovascular procedure to the extracranial ICA.

In our opinion, it could be very helpful for the reader and useful for the clinician to keep in mind that despite Level 1 evidence seems clearly in favor of carotid endarterectomy in symptomatic patients,[234] carotid artery stenting (CAS) has been proposed as a possible alternative in selected cases, if the procedure is performed in a high-volume center with documented low perioperative stroke and death rates.

We have already published our single-center experience reporting the outcome from 43 patients with symptomatic carotid stenosis >70%. In this series, CAS was performed in patients with either a positive history of recurrent transient ischemic attack (TIA) or a single episode of TIA, and in patients suffering from minor stroke, according to the stabilization of cerebral symptoms. The new neurological events rate in the TIA patients at 1 month was 3.8%, while in the minor stroke group, at 1 month, 58.8% of patients experienced an improvement in their initial neurological deficit (decrease in National Institutes of Health Stroke Scale [NIHSS] < 2), the deficit remained stable in 35.3% of patients, and a neurological impairment was found in only one patient.[5]

In a retrospective analysis including 17 patients with AIS and admitted within 7 days of onset, Imai et al.[6] pointed out that emergency CAS placement can improve the 7-day neurologic outcome and may improve the 90-day clinical outcome. Of note, irreversible complications occurred in two patients (12%), including distal embolism in one and intracerebral hemorrhage in the other, while no ipsilateral ischemic stroke recurred.

Some authors have also reported the role of CAS in case of symptomatic “string sign” stenosis. Lesions described as “string sign” or pseudo-occlusions of the common or internal carotid artery are characterized by the appearance of tapering of the vessel lumen and a poststenotic region of significantly reduced caliber. The slow flow and the collapse of the poststenotic region have been thought to be a result of decreased perfusion pressure and decreased flow rather than atherosclerotic disease. Some believe that carotid revascularization for carotid near occlusion is a necessary emergency procedure while others call it dangerous. Historically the presence of string sign detected during carotid angiography has been correlated to high morbidity and mortality risk.[7]

Recently, Nikas et al.[8] reported CAS in patients with severe symptomatic carotid stenosis and angiographic string sign as feasible, with an acceptably low periprocedural complication rate (100% early technical and clinical success).

Some authors[9] have also described emergency endovascular treatment for ICA occlusion in patients who fulfilled the inclusion criteria. The four predefined major exclusion criteria considered were: Admission at >6 h of the onset of stroke symptoms, serious neurologic symptoms (NIHSS ≥ 5), total occlusion of the ICA as shown by the magnetic resonance angiography (MRA) with a diffusion/perfusion mismatch of more than 30%, and a faint visible collateral circulation on MRA. In this particular setting, emergency CAS was performed in 10 patients, revealing to be able to improve the 7-day neurologic outcome and the 90-day clinical outcome.

So, in conclusion, CAS, particulary if associated with intracranial procedures, in the right hands and with the appropriate materials may safely correct a critical stenosis or stabilize the embolic source to the brain, resolving the ischemia in a short time without reduction in cerebral blood flow in the affected hemisphere during the procedure.

References

  1. , , , . Endovascular treatment of acute ischemic stroke: A review. J Neurosci Rural Pract. 2013;4:298-304.
    [Google Scholar]
  2. , , , , , , . The risks and benefits of carotid endarterectomy in patients with near occlusion of the carotid artery. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Neurology. 1997;48:911-5.
    [Google Scholar]
  3. , , , , , . Carotid Endarterectomy Trialists’ Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004;363:915-24.
    [Google Scholar]
  4. , , , , , . Early carotid endarterectomy after ischemic stroke: The results of a prospective multicenter Italian study. Eur J Vasc Endovasc Surg. 2006;32:229-35.
    [Google Scholar]
  5. , , , , . Carotid artery stenting in recently symptomatic patients: A single center experience. Ann Vasc Surg. 2010;24:474-9.
    [Google Scholar]
  6. , , , , , . Emergency carotid artery stent placement in patients with acute ischemic stroke. Am J Neuroradiol. 2005;26:1249-58.
    [Google Scholar]
  7. , , , . Atheromatous pseudo-occlusion of the internal carotid artery. Stroke. 1989;20:1168-73.
    [Google Scholar]
  8. , , , , , , . Carotid artery stenting with proximal cerebral protection for patients with angiographic appearance of string sign. JACC Cardiovasc Interv. 2010;3:298-304.
    [Google Scholar]
  9. , , , . Emergency carotid artery stent insertion for acute ICA occlusion. J Korean Neurosurg Soc. 2010;47:428-32.
    [Google Scholar]

    Fulltext Views
    327

    PDF downloads
    254
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections