Subscribe to RSS
DOI: 10.1055/s-0028-1109343
© Georg Thieme Verlag KG Stuttgart · New York
Langzeitergebnisse nach endovaskulärer Behandlung von Hochrisiko-Patienten mit mehrfach symptomatischen intrakraniellen Stenosen der vertebrobasilären Strombahn
Long-Term Outcome After Endovascular Treatment of High-Risk Patients with Recurrently Symptomatic Intracranial Stenoses of the Posterior CirculationPublication History
eingereicht: 29.9.2008
angenommen: 9.3.2009
Publication Date:
28 April 2009 (online)
![](https://www.thieme-connect.de/media/roefo/200908/lookinside/thumbnails/10.1055-s-0028-1109343-1.jpg)
Zusammenfassung
Ziel: Vorgestellt werden die klinischen und duplexsonografischen Langzeitergebnisse von Hochrisiko-Patienten mit hochgradigen, rezidivierend symptomatischen intrakraniellen Stenosen der vertebrobasilären Achse. Unsere Hypothese ist, dass dieses Kollektiv ein hohes periprozedurales Risiko trägt und trotzdem von der Behandlung im Vergleich mit dem zu erwartenden Spontanrisiko profitiert. Wir vermuteten außerdem, dass die Langzeitergebnisse vom initialen Behandlungsergebnis und der Verwendung von Stents abhängen. Material und Methoden: In einer Analyse unserer prospektiven Datenbank zwischen 1997 und 2006 wurden 72 Patienten identifiziert, von denen 42 Patienten an 45 Stenosen des hinteren Kreislaufs endovaskulär behandelt wurden. Alle Patienten wurden von unabhängigen, in der vaskulären Diagnostik erfahrenen Neurologen klinisch und dopplersonografisch periinterventionell und im Verlauf untersucht. Ergebnisse: Die technische Erfolgsrate lag bei 93 %. In 67 % wurden Stents verwendet. Eine initiale postprozedurale klinische Verschlechterung fand sich nach 30 Tagen bei 24 % der Patienten. 17,8 % der Patienten waren nach durchschnittlich 26,3 Monaten klinisch verschlechtert. 11,1 % der Patienten waren durch die Intervention dauerhaft schwer geschädigt (mRS 3 – 6). 9,5 % der Patienten hatten Restenosen. Ein neuer Schlaganfall konnte im Verlauf der Nachuntersuchung nicht nachgewiesen werden. Schlussfolgerung: Die endovaskuläre Behandlung von Hochrisiko-Patienten mit rezidivierend symptomatischen intrakraniellen Stenosen der vertebrobasilären Achse reduziert deren Schlaganfall- und Mortalitätsrisiko im Verhältnis des zu erwartenden Spontanverlaufs. Die Verwendung von Stents hatte keinen signifikanten Einfluss auf das klinische Langzeitergebnis.
Abstract
Purpose: We present long-term clinical and duplex data from high-risk patients with severe, recurrent symptomatic stenoses of the vertebrobasilar circulation. We hypothesized that despite the greater risk of periprocedural complications in this patient group, interventional treatment would reduce the risk of recurrent strokes relative to the expected natural risk. We also predicted that the long-term treatment outcome would be positively influenced by the use of stents and by the periprocedural technical success rate. Materials and Methods: An analysis of our patient data base yielded 45 cases of stenosis of the vertebrobasilar circulation treated endovascularly in 42 patients between 1998 and 2006. Clinical and vascular diagnostic tests, both periinterventionally and during follow-up, were performed independently by experienced neurologists. Results: The technical success rate was 93 %. Stents were used in 67 % of the procedures. After 30 days, 24 % of the patients showed post-procedural clinical deterioration. After an average period of 26.3 months, 17.8 % of the patients had deteriorated. 11.1 % of the patients suffered severe permanent damage as a result of the procedure (mRs 3 – 6). Restenosis was found in 9.5 % of the cases. There were no instances of a recurrent stroke during follow-up. Conclusion: For this population of high-risk patients with recurrently symptomatic intracranial stenoses of the vertebrobasilar axis, endovascular treatment reduced the risk of stroke and death relative to the expected natural risk. The use of stents had no significant effect on the long-term results.
Key words
CNS - angioplasty - cerebral angiography - stroke - intracranial stenoses
Literatur
- 1 48th Annual Meeting of The Neurosurgical Society of America June 4 – 7, 1995; Sea Island, Georgia. Surg Neurol. 1996; 46 509-512
- 2 Connors J J 3rd , Wojak J C. Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg. 1999; 91 415-423
- 3 Marzewski D J, Furlan A J, St Louis P. et al . Intracranial internal carotid artery stenosis: longterm prognosis. Stroke. 1982; 13 821-824
- 4 Thijs V N, Albers G W. Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology. 2000; 55 490-497
- 5 Chimowitz M I, Kokkinos J, Strong J. et al . The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology. 1995; 45 1488-1493
- 6 Takis C, Kwan E S, Pessin M S. et al . Intracranial angioplasty: experience and complications. Am J Neuroradiol. 1997; 18 1661-1668
- 7 Wong K S, Huang Y N, Gao S. et al . Intracranial stenosis in Chinese patients with acute stroke. Neurology. 1998; 50 812-813
- 8 Collaborators NASCET . Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991; 325 445-453
- 9 Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet. 1996; 347 1591-1593
- 10 Kasner S E, Chimowitz M I, Lynn M J. et al . Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation. 2006; 113 555-563
- 11 Qureshi A I, Ziai W C, Yahia A M. et al . Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: a multicenter study. Neurosurgery. 2003; 52 1033-1039; discussion 1039 – 1040
- 12 Mazighi M, Tanasescu R, Ducrocq X. et al . Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 2006; 66 1187-1191
- 13 Smith W S. Intra-arterial thrombolytic therapy for acute basilar occlusion: pro. Stroke. 2007; 38 701-703
- 14 Kubik C, Adams R. Occlusion of the basilar artery – a clinical and pathological study. Brain. 1946; 19 1216-1222
- 15 Labauge R, Pages M, Marty-Double C. et al . Occlusion du tronc basilaire. Rev Neurol (Paris). 1981; 137 545-571
- 16 Hacke W, Zeumer H, Ferbert A. et al . Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988; 19 1216-1222
- 17 Weimar C, Goertler M, Harms L. et al . Distribution and outcome of symptomatic stenoses and occlusions in patients with acute cerebral ischemia. Arch Neurol. 2006; 63 1287-1291
- 18 Chimowitz M I, Lynn M J, Howlett-Smith H. et al . Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005; 352 1305-1316
- 19 Sacco R L, Adams R, Albers G. et al . Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006; 37 577-617
- 20 Samuels O B, Joseph G J, Lynn M J. et al . A standardized method for measuring intracranial arterial stenosis. Am J Neuroradiol. 2000; 21 643-646
- 21 Baumgartner R W, Mattle H P, Schroth G. Assessment of ≥ 50 % and <50 % intracranial stenoses by transcranial color-coded duplex sonography. Stroke. 1999; 30 87-92
- 22 Seidel G, Klötzsch C, Mäurer M. et al . Stellenwert der transkraniellen Farbduplexsonographie. Dtsch Ärztebl. 2001; 98(11) A-686/B-560/C-527
- 23 Schulte-Altedorneburg G, Droste D W, Popa V. et al . Visualization of the basilar artery by transcranial color-coded duplex sonography: comparison with postmortem results. Stroke. 2000; 31 1123-1127
- 24 Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke. 1988; 19 1497-1500
- 25 Sliwka U, Klotzsch C, Popescu O. et al . Do chronic middle cerebral artery stenoses represent an embolic focus? A multirange transcranial Doppler study. Stroke. 1997; 28 1324-1327
- 26 Diehl R R, Samii C, Diehl A. Dynamics and embolic activity of symptomatic intra-cranial cerebral artery stenoses. Acta Neurol Scand. 2002; 106 173-181
- 27 Lorenz M, Berlit P, Diehl R R. Prädiktoren für die Rückbildung von Gefäßprozessen der A. cerebri media. Nervenarzt. 2003; 74 343-349
- 28 Koch C, Zeumer H. Stentgeschützte Perkutane Angioplastie der Carotis vs. Endarterektomie; SPACE. , http://www.uke.uni-hamburg.de/kliniken/radiologie/neurorad/space/space.de.html 2000
- 29 Koch C, Kucinski T, Eckert B. et al . Endovaskuläre Behandlung hochgradiger Halsgefäßstenosen – Stentgestützte perkutane Angioplastie der Arteria Carotis ohne Protektion. Fortschr Röntgenstr. 2002; 174 1506-1510
- 30 Dorfler A, Struffert T, Engelhorn T. et al . Rotational Flat-Panel Computed Tomography in Diagnostic and Interventional Neuroradiology. Fortschr Röntgenstr. 2008; 180 891-898
- 31 Jiang W J, Xu X T, Du B. et al . Long-term outcome of elective stenting for symptomatic intracranial vertebrobasilar stenosis. Neurology. 2007; 68 856-858
- 32 Fiorella D, Levy E I, Turk A S. et al . US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke. 2007; 38 881-887
- 33 Rothwell P, Warlow C. Is self-audit reliable?. Lancet. 1995; 346 1623
- 34 Marks M P, Marcellus M L, Do H M. et al . Intracranial angioplasty without stenting for symptomatic atherosclerotic stenosis: long-term follow-up. Am J Neuroradiol. 2005; 26 525-530
- 35 Levy E I, Turk A S, Albuquerque F C. et al . Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery. 2007; 61 644-650; discussion 650 – 641
- 36 Gomez C R, Misra V K, Liu M W. et al . Elective stenting of symptomatic basilar artery stenosis. Stroke. 2000; 31 95-99
- 37 Karmonik C, Klucznik R, Benndorf G. Comparison of velocity patterns in an AComA aneurysm measured with 2D phase contrast MRI and simulated with CFD. Technol Health Care. 2008; 16 119-128
- 38 Buhk J H, Lingor P, Knauth M. Angiographic CT with intravenous administration of contrast medium is a noninvasive option for follow-up after intracranial stenting. Neuroradiology. 2008; 50 349-354
- 39 Nahser H C, Henkes H, Weber W. et al . Intracranial vertebrobasilar stenosis: angioplasty and follow-up. Am J Neuroradiol. 2000; 21 1293-1301
- 40 Kim D J, Lee B H, Kim D I. et al . Stent-assisted angioplasty of symptomatic intracranial vertebrobasilar artery stenosis: feasibility and follow-up results. Am J Neuroradiol. 2005; 26 1381-1388
- 41 Lylyk P, Vila J F, Miranda C. et al . Endovascular reconstruction by means of stent placement in symptomatic intracranial atherosclerotic stenosis. Neurol Res. 2005; 27 S84-88
- 42 Bose A, Hartmann M, Henkes H. et al . A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 2007; 38 1531-1537
- 43 Mori T, Fukuoka M, Kazita K. et al . Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. Am J Neuroradiol. 1998; 19 1525-1533
- 44 Marks M P, Wojak J C, Al-Ali F. et al . Angioplasty for Symptomatic Intracranial Stenosis: Clinical Outcome. Stroke. 2006; 37 1016-1020
- 45 Rohr A, Alfke K, Dorner L. et al . Aneurysmabehandlung der Arteria carotis interna mit gecoverten Stents. Fortschr Röntgenstr. 2007; 179 1048-1054
- 46 Higashida R T, Tsai F Y, Halbach V V. et al . Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries. J Neurosurg. 1993; 78 192-198
- 47 Clark W M, Barnwell S L, Nesbit G. et al . Safety and efficacy of percutaneous transluminal angioplasty for intracranial atherosclerotic stenosis. Stroke. 1995; 26 1200-1204
- 48 Aymard A, Houdart E, Boulagr T. et al . Intracranial PTA: indications and results. Neuroradiology. 1997; Endovascular Multimedia Review – August 1997 23-25
- 49 Mori T, Kazita K, Chokyu K. et al . Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. Am J Neuroradiol. 2000; 21 249-254
- 50 Alazzaz A, Thornton J, Aletich V A. et al . Intracranial percutaneous transluminal angioplasty for arteriosclerotic stenosis. Arch Neurol. 2000; 57 1625-1630
- 51 Gress D R, Smith W S, Dowd C F. et al . Angioplasty for intracranial symptomatic vertebrobasilar ischemia. Neurosurgery. 2002; 51 23-27; discussion 27 – 29
- 52 Gupta R, Schumacher H C, Mangla S. et al . Urgent endovascular revascularization for symptomatic intracranial atherosclerotic stenosis. Neurology. 2003; 61 1729-1735
- 53 Henkes H, Miloslavski E, Lowens S. et al . Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (WingSpan). Neuroradiology. 2005; 47 222-228
- 54 du Mesnil de Rochemont R, Berkefeld J, Buchkremer M. et al . Langzeitergebnisse nach Behandlung intrakranieller vertebrobasilärer Stenosen mit Stents. Fortschr Röntgenstr. 2006; 178 96-102
- 55 Turk A S, Levy E I, Albuquerque F C. et al . Influence of patient age and stenosis location on wingspan in-stent restenosis. Am J Neuroradiol. 2008; 29 23-27
Dr. Oliver Wittkugel
Neuroradiologie, Universitätsklinikum Hamburg-Eppendorf
Martinistraße 52
20246 Hamburg
Phone: ++ 49/40/4 28 03 27 46
Fax: ++ 49/40/4 28 03 46 40
Email: wittkugelo@web.de