Intracranial endovascular treatment

Wiebers DO, Whisnant JP, Huston J III et al. (2003). Unruptured intracranial aneurysms natural history, clinical outcome and risks of surgical and endovascular treatment. Lancet 362 103-110... 

Lubicz B, Leclerc X, Levivier M et al. Retractable self-expandable stent for endovascular treatment of widenecked intracranial aneurysms prehminary experience. Neurosurgery. 2006 58 451-457 discussion 451-457... 

Qureshi, A.I. (2004) Endovascular treatment of cerebrovascular diseases and intracranial neoplasms. Lancet, 363 804-813. 

Taschner, C. A., Leclerc, X., Rachdi, H., Barros, A. M. Pruvo, J.-P. (2005) Matrix detachable coils for the endovascular treatment of intracranial aneurysms analysis of early angiographic and clinical outcomes. Stroke, 36, 2176-2180. 

Lot G, Houdart E, Cophignon J, Casasco A and George B (1999), Combined management of intracranial aneurysms by surgical endovascular treatment. Modalities and results from a series of 395 cases , Acta Neurochir (Wien), 141, 557-562. 

Raymond J, Roy D, Leblanc P, et al. (2003) Endovascular treatment of intracranial aneurysms with radioactive coils initial clinical experience. Stroke 34 2801-2806... 

The course of infectious aneurysms is unpredictable. Under antibiotic or antimycotic therapy they may shrink, or completely disappear. However, enlargement during treatment has also been reported (Brust et al. 1990). Septic aneurysms can be obliterated surgically or by endovascular treatment (Chapot et al. 2002 Phuong et al. 2002 Steinberg et al. 1992). The theoretical assumption that implantation of foreign material - like platinum coils - into an infectious lesion might worsen the problem is not true for infectious intracranial aneurysms. Mortality due to rupture of bacterial cerebral aneurysms is reported to be up to 60% (Barrow and Prats 1990 Bohmfalk et al. 1978 Clare and Barrow 1992). 

ISAT was a randomised, prospective, international, controlled trial of endovascular coiling vs surgical clipping for a selected group of patients with ruptured intracranial aneurysms deemed suitable for both types of therapy. Most patients were treated at high-volume centres in the United Kingdom, with the remainders from other European countries, Australia, Canada, and the United States. The primary endpoint was patient outcome, defined as a modified Rankin scale of 3-6 (dependent or deceased) at 1 year. The primary hypothesis was that endovascular treatment would reduce the proportion of patients dependent or deceased by 25% at 1 year. A total of 9559 patients with SAH were screened... 

Flemming KD, Wiebers DO, Brown RD Jr, Link MJ, Huston J III, McClelland RL, Christianson TJ (2005) The natural history of radiographically defined vertebrobasilar nonsaccular intracranial aneurysms. Cerebrovasc Dis 20(4) 270-279. Epub 2005 Aug 22 Forsting M, Albert FK, Jansen O, von Kummer R, Aschoff A, Kunze S, Sartor K (1996) Coil placement after clipping endovascular treatment of incompletely clipped cerebral aneurysms. Report of two cases. J Neurosurg 85 966-969... 

Hademenos GJ, Massoud TF, Turjman F, Sayre JW (1998) Anatomical and morphological factors correlating with rupture of intracranial aneurysms in patients referred for endovascular treatment. Neuroradiology 40 755-760... 

Qureshi AI, Suri MF, Khan J, Kim SH, Fessler RD, Ringer AJ, Guterman LR, Hopkins LN (2001) Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients safety and feasibility. J Neurosurg 94 880-885... 

D, Forsting M (2002) Endovascular treatment of un ruptured intracranial aneurysms. AJNR Am J Neuroradiol 23 756-761... 

Wiebers D, Whisnant JP, Huston J III, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Turner JC (2003) Unruptured intracranial aneurysms natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362 103-110... 

Currie, S., Mankad, K., Goddard, A., 2011. Endovascular treatment of intracranial aneurysms review of current practice. Postgraduate Medical Journal 87, 41-50. 

Pierot, L., Leclerc, X., Bonafe, A., Bracard, S., Registry, F.M., 2008. Endovascular treatment of intracranial aneurysms with matrix detachable coUs midterm anatomic follow-up from a prospective multicenter registry. American Journal of Neuroradiology 29, 57-61. 

Anxionnat R, Bracard S, Ducrocq X, et al. (2001) Intracranial aneurysms Clinical value of 3D digital subtraction angiography in the therapeutic decision and endovascular treatment. Radiology 218 799-808... 

In patients with known chronic cerebral ischemia related to underlying carotid artery stenotic lesions, CBF is usually preserved, at least initially, because of the cerebrovascular reserve. The cerebrovascular reserve represents the vasodilatation ability of cerebral arteries to compensate for a CBF tending to decrease and maintain this CBF at a normal level. In patients with chronic cerebral vascular disorders, it is necessary to quantify the residual cerebrovascular reserve and to distinguish tissue that has used only a limited fraction of its vasodilatation ability and still has cerebrovascular reserve available as a bulfer from tissue that has exhausted its vasodilatation ability and cerebrovascular reserve. The latter is at risk of ischemia, which can be triggered by any hemodynamic stress, and requires intervention to increased CBF, usually through carotid stenosis surgery or endovascular treatment, or extracranial-intracranial artery bypass (Nariai et al. 1995). 

Despite its frequency, the prognosis for patients with symptomatic intracranial stenosis is not well defined. A retrospective study with symptomatic intracranial vertebrobasilar stenosis found that 14% of the patients had another stroke over the 15-month follow-up interval. There has been increasing enthusiasm for endovascular treatment of intracranial artery stenosis (Fig. 40.12). 

Endovascular treatment of aneurysms has focused on the mechanical aspects of the procedures but the prevalence of endoleaks and incomplete obliteration of intracranial aneurysms indicates there is ample room for improvement. An integrated approach where the mechanical device also serves as a scaffold for drug delivery has been proposed. In this scheme, the coils deployed within the aneurysm might also be coated with a drug which promotes intimal hyperplasia and the intimal hyperplasia helps seal the aneurysm neck. 

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