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Cardiology
Treatment of Intracranial Arterial Disease
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
14 sections · 164 slides
Definitions and scope
- Intracranial arterial disease: definition
- Small vessel disease of the brain
- Causes of large intracranial artery occlusion
- In situ arteriopathies of intracranial arteries
- Intracranial atherosclerotic disease defined
- Features unique to intracranial atherosclerosis
- Two compartments of the cerebral circulation
Anatomy and pathophysiology
- Calibre of the circle of Willis vessels
- Lateral middle cerebral artery angiogram with branch legend
- Histology of the intracranial arterial wall
- Anatomical constraints on device navigation
- Circle of Willis as a collateral pathway
- Pial collateral circulation
- Perforating branches and procedural risk
- Named branches the interventionist must know
- Branches of the intracranial vertebral artery
- Normal artery compared with a plaque-narrowed artery
- Atherosclerosis as a systemic dynamic disease
- Imaging methods for diagnosing ICAD
- Longitudinal monitoring of intracranial stenosis
- Progression of MCA occlusive disease
- Clinical events in the Wong cohort
- Rates of progression over time
- Limits of luminal stenosis as a measure of disease
- Arterial cross-sections at increasing degrees of stenosis
- Patterns of arterial remodeling
- Black blood MRI of the intracranial arterial wall
- Remodeling capacity by arterial territory
- Intracranial arterial dolichoectasia
- Intracranial vessel wall imaging in ICAD
- Plaque composition on vessel wall imaging
- Intraplaque haemorrhage
- Contrast enhancement and the culprit lesion
- Typical appearance of ICAD on vessel wall imaging
- Radial plaque location on the middle cerebral artery
Mechanisms of stroke in ICAD
- Mechanisms of infarction in ICAD
- In situ thrombosis and artery-to-artery embolism
- Branch occlusive disease
- Imaging features of symptomatic non-BOD plaques
Epidemiology
- Why ICAD was under-studied
- Gaps in incidence and natural history data
- Prevalence data from population and Doppler studies
- Global stroke burden attributable to ICAD
- Explanations for the Asian predominance
- Moyamoya disease misclassified as ICAD
Asymptomatic intracranial atherosclerosis
- Risk associated with asymptomatic ICAD
- Oxidative stress and endothelial dysfunction
- Biomarkers in the AsIA study
- Endothelial activation versus apoptosis
- Observational outcomes in asymptomatic MCA stenosis
- Symptomatic compared with asymptomatic stroke rates
- Treatment status of asymptomatic ICAD
Symptomatic ICAD and its natural history
- Clinical presentation of symptomatic ICAD
- Infarct patterns caused by ICAD
- Acute presentation and reperfusion options
- Recurrence risk in the WASID trial
- Recurrence risk in the CHANCE subgroup
- Recurrence in the SAMMPRIS medical arm
- Prognosis by lesion location
- Outcomes in basilar artery occlusive disease
- Bilateral intracranial vertebral artery disease
- Stroke-free survival in vertebrobasilar stenosis
- Middle cerebral artery compared with basilar stenosis
- Long-term follow-up of symptomatic MCA stenosis
Medical management
- Warfarin compared with aspirin in WASID
- WASID efficacy and safety results
- WASID subgroup analysis by lesion site
- Low molecular weight heparin in the FISS-tris study
- FISS-tris outcomes
- Antithrombotic strategy in symptomatic ICAD
- Dual antiplatelet regimen in the trial medical arms
- Event rates in the modern medical arms
- Timing of risk reduction after the index event
- Microembolic signals in the CLAIR study
- Evidence for dual antiplatelets at 50% stenosis
- CHANCE imaging subgroup results
- Cilostazol combinations in the TOSS trials
- TOSS-2 results
Endovascular treatment of stenosis
- Aims of angioplasty and stenting
- Design of the SAMMPRIS trial
- SAMMPRIS results
- Conclusions and criticism of SAMMPRIS
- The VISSIT trial
- Balloon-mounted stent expanded across an atherosclerotic lesion
- Single-centre randomised study of MCA stenting
- Operator experience and credentialing
- Patient selection beyond stenosis severity
- Lesion characteristics that raise procedural risk
- Stenting in perforator-related disease
- Prospective Chinese Wingspan stenting study
- Enterprise stent with undersized angioplasty
- The CASSISS trial
- Rationale for primary angioplasty alone
- Primary balloon angioplasty in the Okada series
- Submaximal angioplasty phase 1 study
- Submaximal angioplasty outcomes
- Submaximal balloon angioplasty of a severe middle cerebral artery stenosis
- Guideline and regulatory position on PTAS
- Management algorithm for suspected intracranial atherosclerotic disease
Acute large vessel occlusion from atherosclerosis
- Proportion of large vessel occlusions from in situ disease
- Difficulty of identifying the mechanism acutely
- Emergent basilar artery angioplasty and stent placement
- Stent retriever thrombectomy in atherosclerotic occlusion
- Rescue treatments and outcomes after failed thrombectomy
- Acute intracranial stenting in stroke in evolution
- The SARIS trial
- Reocclusion after emergent angioplasty or stenting
- Current status of acute endovascular treatment in ICAD
Periprocedural management
- Antiplatelet preparation for elective cases
- Urgent loading and clopidogrel resistance
- Antiplatelet management in emergent cases
- Post-procedure imaging and antiplatelet initiation
- Parenteral antiplatelet for intraprocedural thrombosis
- Invasive arterial blood pressure monitoring
- Vasoactive drugs for the procedure
- Managing preprocedural antihypertensives
- Why blood pressure control matters in ICAD
- Reperfusion injury after recanalisation
- Acute hypertensive response
- Cerebrovascular reserve in chronic ischaemia
- Blood pressure and outcome in acute ischaemic stroke
- Permissive hypertension during reperfusion
- Open questions in blood pressure modulation
Surgical revascularisation
- Extracranial-intracranial bypass surgery
- The Carotid Occlusion Surgery Study
- Encephaloduroarteriosynangiosis
- Current status of EDAS in ICAD
Aggressive medical management
- The main lesson from SAMMPRIS
- Comparing the SAMMPRIS and WASID medical arms
- Components of aggressive medical management
- Residual risk despite aggressive management
- Predictors of recurrence despite medical therapy
- Limits of extrapolation to asymptomatic disease
Clinical recommendations
- Sequence of management in symptomatic ICAD
- Recommended medical therapy for intracranial stenosis
- Recommended antiplatelet duration
- Recommended role of endovascular therapy
- Summary of key points
References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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