Biomedical subjects

R D Fessler

Publications and source records attributed to R D Fessler.

At least 19 recordsLinked to original sources

PubMed2001

Angioplasty for cerebral vasospasm from eclampsia.

BACKGROUND: Neurological deterioration in eclampsia is considered to be secondary to cerebral vasospasm. Magnesium sulfate therapy improves symptoms and controls seizures, possibly related to its vasorelaxive effects in spastic arteries. Some cases, however, are refractory to magnesium therapy. To our knowledge, there is no report of angioplasty for vasospasm from eclampsia in the literature. METHODS: A 27-year-old woman presented 10 days postpartum with severe mental status changes and left arm and bilateral leg weakness that were refractory to magnesium therapy. Cerebral angiography demonstrated diffuse, severe vasospasm. We treated her with angioplasty of the bilateral middle and posterior cerebral arteries, basilar artery, and bilateral internal carotid arteries. RESULTS: Angioplasty resulted in excellent angiographic improvement. The patient immediately became responsive and appropriate with improved strength in all extremities. She continued to improve throughout her hospital stay and was discharged 10 days postangioplasty. CONCLUSIONS: Cerebral angioplasty is an effective treatment for vasospasm from eclampsia refractory to magnesium therapy. Angiography should be considered early in the course of neurological deterioration, but delayed therapy may also be effective.

Adult↗

PubMed2001

Open-label phase I clinical study to assess the safety of intravenous eptifibatide in patients undergoing internal carotid artery angioplasty and stent placement.

OBJECTIVE: Eptifibatide, a competitive platelet glycoprotein IIb-IIIa receptor inhibitor with high selectivity and a short half-life, has been demonstrated to reduce the risk of ischemic events associated with coronary interventions. However, its role in neurointerventional procedures needs to be analyzed. We report the results of an open-label Phase I study to evaluate the safety of the use of eptifibatide during carotid angioplasty and stent placement. METHODS: Each study patient received eptifibatide administered intravenously as a 135-microg/kg single-dose bolus, then a 0.5-microg/kg/min infusion for 20 to 24 hours during carotid angioplasty and stent placement. The primary efficacy end point was the 30-day composite occurrence of death, cerebral infarction, transient ischemic attack, and unplanned or urgent surgical intervention, thrombolysis, or subsequent percutaneous revascularization. The primary safety end point was bleeding. Bleeding complications were classified as major (hemoglobin decrease >5 g/dl), minor (hemoglobin decrease 3-5 g/dl), or insignificant. RESULTS: Ten patients (mean age, 73 yr; four men) were treated by use of the study protocol. One patient developed a minor stroke postprocedurally (National Institutes of Health Stroke Scale score of 21 at 24 h that improved to 1 at 7 d). Three patients underwent scheduled coronary artery bypass graft surgery 4 to 12 days after undergoing carotid angioplasty and stent placement. At 1-month follow-up, no new ischemic events were observed. Major or minor bleeding was not observed in any patient. Insignificant bleeding was observed in two patients. CONCLUSION: The use of eptifibatide as an adjunct to carotid angioplasty and stent placement seems to be safe. Further studies are required to analyze the effectiveness and role of eptifibatide in neurointerventional procedures.

Aged↗

PubMed2001

Angioplasty of intracranial occlusion resistant to thrombolysis in acute ischemic stroke.

OBJECTIVE: Thrombolysis has been demonstrated to improve revascularization and outcome in patients with acute ischemic stroke. Many centers now apply thrombolytic therapy locally via intra-arterial infusion. One therapeutic benefit is the ability to cross soft clots with a guidewire and to perform mechanical thrombolysis. In some instances, reopened arteries reocclude as a result of either thrombosis or vasospasm. We report the use of balloon angioplasty during thrombolysis for acute stroke. METHODS: From June 1995 through June 1999, 49 patients underwent intra-arterial therapy for acute stroke. In this group, nine patients (seven men and two women) were treated with balloon angioplasty after inadequate recanalization with thrombolytic infusion. The mean age of these patients was 67.9 years. Nine matched control patients who underwent thrombolysis alone without angioplasty were chosen for comparison. RESULTS: In the group of nine patients who had angioplasty, the mean National Institutes of Health Stroke Scale score at presentation was 21.8 +/- 5.4. Four patients had residual distal occlusion after angioplasty, and one patient had a hemorrhagic conversion. Of the five patients in which recanalization was successful, none had reocclusion of the balloon-dilated vessel. The mean score at 30 days for the five survivors was 12.6 +/- 14.9, for an improvement of 7.0 +/- 14.2. Among the nine control patients, the mean score at presentation was 20.3 +/- 5.2; the mean score at 30 days for the five survivors was 19.4 +/- 7.7, for an improvement of 4.2 +/- 7.8. CONCLUSION: In our experience, balloon angioplasty is a safe, effective adjuvant therapy in patients who are resistant to intra-arterial thrombolysis. The use of balloon angioplasty may prevent reocclusion in a stenotic artery and permit distal infusion of thrombolytic agents.

Aged↗

PubMed2001

Role of conventional angiography in evaluation of patients with carotid artery stenosis demonstrated by Doppler ultrasound in general practice.

BACKGROUND AND PURPOSE: Previous studies have suggested that patients with carotid stenosis who are candidates for endarterectomy can be effectively identified on the basis of carotid Doppler ultrasound alone. Before widespread acceptance of this policy, the accuracy of carotid Doppler ultrasound outside selected centers and clinical trials needs to be evaluated. We performed a 12-month prospective study to evaluate the accuracy of Doppler ultrasound in identifying patients for carotid intervention in general practice settings. METHODS: Each patient referred to our endovascular service for diagnostic angiography to evaluate for carotid stenosis was interviewed and examined by a neurologist. Subjects consisted of symptomatic patients with >/=50% stenosis and asymptomatic patients with >/=60% stenosis by Doppler ultrasound. Information pertaining to demographic and cerebrovascular risk factors and the results of the carotid Doppler ultrasound were recorded. The severity of stenosis on angiograms was measured with North American Symptomatic Carotid Endarterectomy Trial criteria by a blinded observer. The results of both studies were compared to determine the relative accuracy of ultrasound results. RESULTS: Of 130 patients (mean age, 69+/-8.8 years) who met Doppler ultrasound criteria, 22 (17%) and 8 patients (6%) were found to have 30% to 49% or <30% stenosis by angiography, respectively. The positive predictive value of carotid Doppler ultrasound for identifying appropriate symptomatic candidates for carotid intervention (angiographic stenosis >/=50%) was 80%, with a false-positive value of 20%. The positive predictive value of carotid Doppler ultrasound for identifying appropriate asymptomatic candidates for carotid intervention (angiographic stenosis >/=60%) was 59%, with a false-positive value of 41%. Carotid endarterectomy or angioplasty and stent placement were undertaken subsequently in 60 (46%) of the patients. In 94 patients who underwent cerebral angiography alone, no complications were observed. CONCLUSIONS: The present accuracy of carotid Doppler ultrasound in general practice does not justify its use as the sole basis of selecting appropriate patients for carotid intervention. Given the relatively low rate of associated morbidity with present day techniques, additional confirmatory studies such as angiography should be performed in every patient before a decision regarding intervention is made.

Aged↗

PubMed2001

Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: safety and feasibility.

OBJECT: Embolization of intracranial aneurysms performed using Guglielmi detachable coils (GDCs) is performed with the patient in a state of general anesthesia at most centers. Such an approach does not allow intraprocedural evaluation of the patient's neurological status and carries additional risks associated with general anesthesia and mechanical ventilation. At the authors' institution, GDC embolization of intracranial aneurysms is performed in awake patients after administration of sedative and analgesic agents (midazolam, fentanyl, morphine, and/or hydromorphone). To determine the feasibility and safety of this approach, the authors have retrospectively reviewed their clinical experience. METHODS: The authors reviewed the medical records of all patients in whom GDC embolization for the treatment of intracranial aneurysms was undertaken between February 1, 1990 and October 31, 1999. Clinical presentation, medical comorbidities, anesthetic agents used, intraprocedural complications, and final procedural outcome were recorded for each patient. Guglielmi detachable coil embolization was attempted in the awake patient in 150 procedures. Among 92 procedures for unruptured aneurysms, 75 (82%) were completed without complications. Four procedures were completed with complications. Of the 92 procedures, 13 were aborted due to patient uncooperativeness (one patient), complications (three patients), morphological characteristics of the aneurysm or surrounding vessels that made embolization technically difficult (eight patients), or vasospasm (one patient). Among 58 procedures for ruptured aneurysms, the procedure was completed without complication in 48 cases (83%). The procedure was completed with complications in five cases and two patients required induction of general anesthesia during the procedure. Five procedures were aborted because morphological characteristics of the aneurysm or surrounding vessels made embolization technically difficult (two patients) or because of aneurysm rupture (two patients) or the appearance of a transient neurological deficit (one patient). CONCLUSIONS: Embolization of intracranial aneurysms performed using GDCs in the awake patient appears to be safe and feasible and allows intraprocedural evaluation of the patient. Potential advantages, including decreased cardiopulmonary morbidity rates, shorter hospital stay, and lower hospital costs, still require confirmation by a direct comparison with other anesthetic procedures.

Adult↗

PubMed2000

Horner's syndrome after carotid artery stenting: case report.

BACKGROUND: Angioplasty and stenting of various lesions of the carotid artery is gaining in popularity. Our knowledge of the efficacy and limitations of this promising technology is incomplete. Although Horner's syndrome and its variants have been described after traumatic, spontaneous, or surgical carotid dissection, it has not been reported after carotid artery stenting. CASE DESCRIPTION: A 36-year-old woman presented with left neck and ear pain and a 3-year history of rushing noises in her left ear. Angiography demonstrated evidence of dissection of the left internal carotid artery at the skull base with a pseudoaneurysm. The pseudoaneurysm was treated with a 6-mm diameter self-expanding stent in a 4-mm diameter left internal carotid artery. A few hours later, she developed partial Horner's syndrome with a subtle ipsilateral ptosis and miosis without anhidrosis. Angiography performed on the next day did not demonstrate further dissection or aneurysm growth but did show distention of the artery wall because of the stent. She did not develop any further sequelae. CONCLUSION: This case suggests that stretching of the artery wall may result in stretching of surrounding structures. The sympathetic fibers surrounding the internal carotid artery are clearly sensitive to this degree of stretch. Possible complications associated with stretch injury must be considered when choosing the stent diameter.

Adult↗

PubMed2000

Abciximab as an adjunct to high-risk carotid or vertebrobasilar angioplasty: preliminary experience.

OBJECTIVE: Abciximab, a platelet glycoprotein IIb/IIIa receptor inhibitor, has been shown to reduce the risk of ischemic events associated with coronary intervention. However, its role in neurointerventional procedures needs to be defined. We prospectively evaluated our initial experience with the use of abciximab in a series of high-risk patients undergoing carotid, basilar, or vertebral artery angioplasty. METHODS: Patients were given an intravenous abciximab bolus (0.25 mg/kg), followed by infusion (10 microg/min) for a period ranging from 12 to 24 hours, as an adjunct to angioplasty in 20 procedures (19 patients). These patients were considered to be at high risk for thromboembolic events because of recent ischemic symptoms and/or complex lesion morphology. Before, immediately after, and 24 hours after the procedure, each patient was evaluated by a neurologist for the presence of new neurological deficits. Any bleeding or other complications during hospitalization were also recorded. Bleeding was defined as major (hemoglobin decrease >5 g/dl), minor (hemoglobin decrease 3-5 g/dl), or insignificant. RESULTS: Angioplasty was performed in the internal carotid artery (n = 13), vertebral artery (n = 4), or basilar artery (n = 2). Stents were placed across 13 lesions. In one patient, angioplasty could not be performed owing to technical difficulties; however, abciximab was administered because of extensive lesion manipulation. Intraprocedural heparin was given in 19 procedures (35-86 U/kg intravenously) and partially reversed in 6 procedures. Low-dose intra-arterial thrombolytic agents were administered in seven patients before the lesion was crossed. Two patients experienced transient neurological deficits either during (n = 1) or immediately after (n = 1) the procedure. Another patient had complete occlusion of the right vertebral artery after angioplasty with complete recanalization after 24 hours of abciximab infusion. Major or minor bleeding was not observed in any patient. Insignificant bleeding was observed in eight patients. Thrombocytopenia was observed in one patient who received concomitant administration of intravenous heparin and abciximab infusion. CONCLUSION: We observed a low frequency of neurological events in high-risk patients undergoing angioplasty with or without stent placement. Abciximab seems to be a relatively safe adjunct for carotid or vertebrobasilar endovascular intervention either alone or in combination with low-dose thrombolytics. Partial reversal of intraprocedural heparin should be considered to reduce the risk of postprocedural bleeding.

Abciximab↗

PubMed2000

Transradial approach for vertebral artery stenting: technical case report.

OBJECTIVE: We report the technique of transradial vertebral artery stenting for two patients in whom severe supra-aortic ectasia prevented ready access to the right vertebral artery origin. METHODS: An Allen test was performed to verify ulnar artery collateral flow in the hand. After the administration of local anesthesia, a 6-French sheath was introduced into the radial artery. To allay induced spasm, a mixture of heparin (5000 IU/ml), verapamil (2.5 mg), nitroglycerine (400 microg/ml, 0.25 ml), and lidocaine (2%, 1.0 ml) was infused through the introducer sheath. A microguidewire was positioned across the vertebral artery lesion, followed by placement of a balloon-expandable stent. RESULTS: Postdeployment angiography revealed improved vertebrobasilar system flow. There were no complications related to the radial artery. The patients tolerated the procedure without difficulty and were immediately ambulatory. CONCLUSION: This novel approach should be considered for endovascular procedures for which access to the vertebral artery origin via the femoral approach is limited.

Aged↗

PubMed2000

Cervical carotid revascularization.

The use of angioplasty and stent techniques for revascularization of the cervical carotid bifurcation has been limited. Carotid endarterectomy has been demonstrated to be safe and effective in two multicentered randomized trials. In patients who are considered at risk for excessive morbidity and mortality from open surgical revascularization, carotid endovascular revascularization provides a good alternative. This article outlines the indications, methods, complications and perioperative management of patients treated with balloon angioplasty and stent of the cervical carotid bifurcation.

Carotid Arteries↗

PubMed2000

Intracranial stent placement to trap an extruded coil during endovascular aneurysm treatment: technical note.

OBJECTIVE: The development of low profile, navigable stents has expanded the range of intracranial neuroendovascular procedures. We report a unique case of endovascular stent placement to trap a partially extruded Guglielmi detachable coil (GDC) during treatment of an internal carotid artery (ICA) cavernous segment aneurysm. METHODS: A 49-year-old woman presented for endovascular coiling of a left superior hypophyseal artery aneurysm. Previously, a contralateral mirror lesion had been treated by stent-assisted coiling. Heparin was administered to maintain an activated coagulation time of greater than 250 seconds, and a guide catheter was placed in the cervical ICA. A microcatheter was advanced into the aneurysm over a microguidewire. A GDC-10, 3-dimension, 6 x 20-mm coil was placed within the aneurysm, forming a stable basket. Three additional GDCs were placed with near-complete obliteration of the aneurysm. Attempted placement of a fifth coil caused partial prolapse of a previously placed coil into the cavernous ICA. We decided to place a stent rather than to snare the extruded coil because the extruded coil was integral to the aneurysm coil mass. A 3.5x8-mm balloon-expandable stent was placed across the aneurysm orifice, trapping the extruded coil between the stent and ICA. RESULTS: Digital subtraction angiography documented patency of the ICA lumen. The patient remains neurologically intact and awaits 3-month follow-up cerebral angiography. CONCLUSION: Trapping of an extruded intraaneurysmal coil via stent placement obviated the need for coil removal and avoided the risk of coil mass manipulation. The use of a stent to displace extruded coils and reconstitute a "normal" lumen is an excellent addition to our endovascular armamentarium.

Carotid Artery, Internal↗

PubMed2000

Intraarterial recombinant tissue plasminogen activator for ischemic stroke: an accelerating dosing regimen.

OBJECTIVE: Urokinase has been conventionally used for intraarterial thrombolysis in acute ischemic stroke. Recently, due to the withdrawal of urokinase from the market, attention has been focused on recombinant tissue plasminogen activator (r-tPA) for intraarterial administration. Data is limited regarding the intraarterial dose, efficacy, and safety profile of this agent. METHODS: We prospectively studied 8 consecutive patients with acute ischemic stroke who were referred for intraarterial lysis. Each patient was considered by the treating neurologist to be a poor candidate for intravenous therapy. We administered a maximum total dose of 40 mg of r-tPA intraarterially via superselective catheterization. Angiograms were obtained after each 10 mg of r-tPA, and responses were graded using modified Thrombolysis in Myocardial Infarction (TIMI) criteria for perfusion and degree of thrombus. RESULTS: Initial National Institutes of Health Stroke Scale (NIHSS) scores ranged from 16 to 21. Intervals from presentation to treatment initiation ranged from 1 to 8 hours. After administration of r-tPA, neurological improvement (decrease in NIHSS score > or =2) was observed in 4 patients. Mean perfusion grade improved from a pretreatment score of 0 with increasing doses of r-tPA to 1.1 +/- 1.0 with 10 mg, 1.5 +/- 1.4 with 20 mg, 2.0 +/- 0.8 with 30 mg, and 2.7 +/- 1.0 with 40 mg. Mean thrombus degree decreased from a pretreatment score of 4 with increasing doses of r-tPA to 2.8 +/- 1.2 after 10 mg, 2.6 +/- 1.4 after 20 mg, 1.9 +/- 1.5 after 30 mg, and 1.4 +/- 1.5 after 40 mg. Asymptomatic intraparenchymal hemorrhage was observed on CT scan in 2 patients at 24 hours. CONCLUSION: Our study suggests that intraarterial r-tPA in doses up to 40 mg is relatively safe. The dose appears to facilitate the recanalization process by lysis of local thrombus and improvement in distal flow.

Adolescent↗

PubMed1999

Angioplasty and stenting of basilar artery stenosis: technical case report.

OBJECTIVE AND IMPORTANCE: Symptomatic basilar artery stenosis has a poor prognosis. Treatment options are limited. Surgical bypasses are technically demanding and of no proven benefit. Percutaneous angioplasty is associated with a significant complication rate, because of intraplaque dissection, restenosis secondary to vessel recoil, and embolic phenomena. A new generation of intravascular stents that are flexible enough to navigate the tortuosities of the vertebral artery may provide a new therapeutic approach. We report a case of basilar artery stenosis that was treated using stent-assisted angioplasty. CLINICAL PRESENTATION: A 56-year-old woman experienced a vertebrobasilar ischemic stroke, from which she recovered. Magnetic resonance angiography revealed severe proximal basilar artery stenosis. Brain Neurolite-single-photon emission computed tomographic scans revealed significantly decreased perfusion of the brainstem. Endovascular intra-arterial pressure measurements revealed a 35-mm Hg gradient across the lesion. INTERVENTION: The patient underwent uncomplicated angioplasty and stenting of the proximal basilar artery, with excellent angiographic results. CONCLUSION: The availability of new flexible intravascular stents, allowing access to tortuous proximal intracranial vessels, provides a new therapeutic approach for patients with basilar artery stenosis. Long-term follow-up monitoring is required to assess the durability of this approach.

Angiography, Digital Subtraction↗

PubMed1999

Improved cerebral perfusion after stenting of a petrous carotid stenosis: technical case report.

OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using 99mTc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain 99mTc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.

Aged↗

PubMed1999

Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms.

OBJECT: Results of previous in vitro and in vivo experimental studies have suggested that placement of a porous stent within the parent artery across the aneurysm neck may hemodynamically uncouple the aneurysm from the parent vessel, leading to thrombosis of the aneurysm. For complex wide-necked aneurysms, a stent may also aid packing of the aneurysm with Guglielmi detachable coils (GDCs) by acting as a rigid scaffold that prevents coil herniation into the parent vessel. Recently, improved stent system delivery technology has allowed access to the tortuous vascular segments of the intracranial system. The authors report here on the use of intracranial stents to treat aneurysms involving different segments of the internal carotid artery (ICA), the vertebral artery (VA), and the basilar artery (BA). METHODS: Ten patients with intracranial aneurysms located at ICA segments (one petrous, two cavernous, and three paraclinoid aneurysms), the VA proximal to the posterior inferior cerebellar artery origin (one aneurysm), or the BA trunk (three aneurysms) were treated since January 1998. In eight patients, stent placement across the aneurysm neck was followed (immediately in four patients and at a separate procedure in the remaining four) by coil placement in the aneurysm, accomplished via a microcatheter through the stent mesh. In two patients, wide-necked aneurysms (one partially thrombosed BA trunk aneurysm and one paraclinoid segment aneurysm) were treated solely by stent placement; coil placement may follow later if necessary. No permanent periprocedural complications occurred and, at follow-up examination, no patient was found to have suffered symptoms referable to aneurysm growth or thromboembolic complications. Greater than 90% aneurysm occlusion was achieved in the eight patients treated by stent and coil placement as demonstrated on immediate postprocedural angiograms. Follow-up angiographic studies performed in six patients at least 3 months later (range 3-14 months) revealed only one incident of in-stent stenosis. In the four patients originally treated solely by stent placement, no evidence of aneurysm thrombosis was observed either immediately postprocedure or on follow-up angiographic studies performed 24 hours (two patients), 48 hours, and 3 months later, respectively. CONCLUSIONS: A new generation of flexible stents can be used to treat complex aneurysms in difficult-to-access areas such as the proximal intracranial segments of the ICA, the VA, or the BA trunk. The stent allows tight coil packing even in the presence of a wide-necked, irregularly shaped aneurysm and may provide an endoluminal matrix for endothelial growth. Although convincing experimental evidence suggests that stent placement across the aneurysm neck may by itself promote intraluminal thrombosis, the role of this phenomenon in clinical practice may be limited at present by the high porosity of currently available stents.

Adult↗

PubMed1999

Successful intracranial thrombolysis for cerebral thromboembolic complications resulting from cardiovascular diagnostic and interventional procedures.

We report successful local thrombolysis to treat intracranial ischemic complications of angioplasty with stenting of a high-grade carotid artery stenosis, angioplasty with thrombolysis of an occluded venous graft, and routine coronary angiography. Intracranial complications occurring during cardiovascular diagnostic or interventional procedures can be reversed with prompt management via rescue thrombolysis. These events should not be viewed as irreversible complications, and the opportunity for intracranial thrombolysis should be available wherever cardiovascular interventional procedures are performed. The ability to quickly recognize and remedy complications occurring during these procedures is another step in the continued advancement of neuroendovascular therapy.

Aged↗

PubMed1998

Angioplasty and stenting for carotid artery stenosis: indications, techniques, results, and complications.

Following the favorable results obtained in the treatment of coronary artery disease, combined angioplasty and stenting has been advocated for the treatment of carotid artery stenosis as well. Although widespread application of angioplasty and stenting for carotid artery disease is neither indicated nor recommended, it may be a viable alternative therapy for select patients who are high-risk patients for surgery. The results of early series have suggested that endoluminal revascularization in these high-risk patients can be performed with an acceptable degree of safety. Although the incidence of death and major stroke rates following angioplasty and stenting procedures compares favorably with surgery, results of more recent clinical series have suggested that the incidence of perioperative transient neurological events and minor strokes may be higher than suggested by earlier reports, especially in patients with recent neurological symptoms and "unstable" plaques. In this article, the authors review the current potential indications for and preliminary results of angioplasty and stenting and describe their procedural technique. In addition, potential applications of stenting to intracranial thromboocclusive carotid artery disease are reviewed.

Journal Article↗

PubMed1998

Stent placement for vertebral artery occlusive disease: preliminary clinical experience.

Symptoms of vertebrobasilar insufficiency may precede neurological sequelae in up to 50% of patients. Although select patients may benefit from microsurgical revascularization, combined perioperative morbidity and mortality rates can be as high as 20%. The authors present their preliminary clinical experience using stent placement for symptomatic vertebral artery (VA) occlusive disease. Six patients with clinical symptoms of vertebrobasilar insufficiency in whom VA stents were placed from 1995 to 1998 were identified. Diagnostic four-vessel cerebral angiography identified causative stenotic, atherosclerotic lesions in all cases. A transfemoral or transradial artery approach after the patient had undergone full heparinization was chosen for endovascular stenting. Guidewire placement across the lesion followed by urokinase infusion preceded stenting. Prestent angioplasty was performed in two patients. Following the procedure, all patients were maintained on daily antiplatelet therapy. Patient age ranged from 45 to 76 years (average 63 years). Four patients were men and two were women. Angiography revealed greater than 95% stenosis in five patients and greater than 70% stenosis in one. Three patients had complete occlusion of the contralateral VA; in one other, the VA supplied only the posterior inferior cerebellar artery; and the remaining two patients had VAs with greater than 70% stenosis. Ten stents were placed in six patients for five VA origin lesions and one distal VA stenosis. A VA dissection occurring poststenting was treated by placement of three additional stents. One patient had transient double vision. All had resolution of their presenting symptoms. Follow up ranged from 1 to 24 months (average 8.4 months). Angiograms obtained in four patients at least 3 months postprocedure have revealed stent patency in all cases without evidence of restenosis. Vertebral artery stent placement can be safely performed and is a viable treatment option for carefully selected patients with vertebrobasilar insufficiency.

Journal Article↗

PubMed1998

Management of elevated intracranial pressure in patients with Cryptococcal meningitis.

BACKGROUND: The most important predictor of early mortality in patients with HIV-associated cryptococcal meningitis is mental status at presentation; patients who present with altered mental status have up to 25% mortality. Historically, cerebrospinal fluid (CSF) diversion in HIV-negative patients with cryptococcal meningitis and signs of elevated intracranial pressure (ICP) has improved survival. In an effort to affect survival and morbidity rates in patients with HIV-associated cryptococcal meningitis, we have initiated aggressive management of elevated ICP in patients with focal neurologic deficits, mental obtundation, or both. METHODS: We identified 10 patients with HIV-associated cryptococcal meningitis who presented with symptoms consistent with elevated ICP, including headache, mental obtundation, papilledema, and cranial nerve palsies. Elevated opening pressure was defined as > 20 cm CSF during lumbar puncture. In patients with elevated opening pressures who had focal neurologic deficits or mental status changes refractory to serial lumbar puncture, management consisted of immediate placement of lumbar drains for continuous drainage of CSF to maintain normal ICP (10 cm CSF). Patients with persistent elevations of spinal neuraxis pressure following lumbar drainage underwent placement of lumbar peritoneal shunts. RESULTS: All patients returned to their baseline level of consciousness following normalization of ICP. Two patients were weaned from lumbar drainage. Eight patients eventually required placement of lumbar peritoneal shunts for persistently elevated ICP despite successful antifungal therapy. Follow-up ranged from 1 to 15 months. One shunt infection occurred, one lumbar peritoneal shunt was converted to a ventriculoperitoneal shunt, and one shunt was removed. CONCLUSIONS: Elevated ICP in patients with HIV-associated cryptococcal meningitis is a significant source of morbidity and mortality. The use of lumbar drainage and selective placement of lumbar peritoneal shunts in the management of elevated ICP in patients with HIV-associated cryptococcal meningitis can ameliorate the sequelae of elevated ICP.

Adult↗