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Endovascular Therapy for the Treatment of Cerebrovascular Disease
Abbreviations
3D
three dimensional
ACoA
anterior communicating artery
ADAPT
a direct aspiration first-pass technique
AP
anteroposterior
AVM
arteriovenous malformation
CT
computed tomographic
CTA
CT angiography
DMSO
dimethyl sulfoxide
DSA
digital subtraction angiography
FRED
Flow redirection endoluminal device
IA
intracranial aneurysm
ISAT
International Subarachnoid Aneurysm Trial
ISUIA
International Study of Unruptured Intracranial Aneurysms
IVH
intraventricular hemorrhage
LVIS
Low-profile visualized intraluminal support
MCA
middle cerebral artery
NBCA
N-butylcyanoacrylate
NIHSS
National Institutes of Health Stroke Scale
PED
pipeline embolization device
SWIFT
SOLITAIRE FR with the intention for thrombectomy
TICI
thrombolysis in cerebral infarction
tPA
tissue plasminogen activator
TREVO 2
Trevo versus Merci Retrievers for Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke
VA
vertebral artery
Introduction
Endovascular approaches to the central nervous system have evolved tremendously over the last decade. It is one of the most rapidly growing specialties in neurosurgery and in medicine. The early 1980s were marked by primitive technologies associated with long and risky procedures and high rates of complications, often resulting in major catastrophes. As of 2016, neuroendovascular technology and procedures have evolved to the point that nowadays these interventions are performed routinely and safely at most major medical centers. Some of the applications of neuroendovascular technology in the treatment of cerebrovascular diseases include ischemic stroke, intracranial aneurysms (IAs), intracranial arteriovenous malformations (AVMs) and fistulas, and extracranial vascular diseases (e.g., carotid artery stenosis). In this chapter, we present the current status of neuroendovascular management of these cerebrovascular diseases.
Stroke
Stroke is the leading cause of long-term disabilities in America and the second most common cause of mortality worldwide. Ischemic stroke is the prevalent stroke type in 87% of patients. Less than 4% of them are treated with intravenous thrombolysis with recombinant tissue plasminogen activator (tPA) . Most patients do not qualify for tPA therapy due to delayed presentation or multiple exclusion criteria. Endovascular management is an alternative for some of these patients. Intraarterial revascularization is indicated in patients with National Institutes of Health Stroke Scale (NIHSS) scores of ≥8, which may indicate a large-vessel occlusion. Endovascular revascularization targets patients with large-vessel occlusion. Exceptions include patients with severe visual deficit or isolated severe aphasia for whom endovascular therapy could be indicated even if the NIHSS score is <8. Endovascular technology for stroke has also evolved over the last few years . Most recent trials have reported successful recanalization in approximately 85% of the cases compared to 50% with earlier technologies [e.g., pharmacological intraarterial thrombolysis or mechanical thrombectomy with the Merci retriever (Stryker Neurovascular)] . With the publication of five randomized controlled trials in 2015 , mechanical thrombectomy, when used in combination with intravenous tPA, has demonstrated a significant radiographic and clinical benefit over traditional strategies with intravenous tPA alone. These results have placed endovascular therapy at the forefront of stroke treatment, redefining the standard of care ( Fig. 149.1 ) . Currently, stent retriever thrombectomy and primary aspiration thrombectomy are the most commonly used endovascular techniques in stroke intervention .
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