Matthew Tenser, MD, a neurological surgeon at Keck Medicine of USC, discusses intracranial occlusive disease, including its prevalence in the population and available treatment options.
Yeah. Hi. My name is Matthew. 10, Sir. Thank you for watching our presentation today. I'll be speaking on intracranial atherosclerotic disease disease. Uh, I'm an interventional neurologists and vascular neurologist here at USC on I'll present on intracranial stenosis today. So as far as a brief introduction, there's about 800,000 strokes a year in the US, about 10% of which are due to integrate narrowing or Afro sclerosis. As you can see on the picture here with the arrow, there's a obvious narrowing or even almost occlusion on that blood vessel. Uh, internal cyanosis is relatively common. We find it to be in about 3 to 13% of patients. Uh, the risk of stroke is pretty variable, depending on how tight it is, where it is and what the other blood vessel connections are up in the brain. But the risk of stroke has been estimated to be anywhere from 7 to 40% over one year, with the recurrent risk of stroke after that first, one of up to 50% it's more common in certain populations, such as Asians or African Americans, and, for example, in China is responsible for almost 50% of strokes in their patients. How does it cause a stroke? Or there's several different ways. Number one in where the narrowing actually is a clot conform due to irregular blood flow. Uh, there are certain things that could make it more likely to form a clot, such as a rupture of a plaque or alteration of a plaque or hematoma. Inside the atherosclerotic plaque at the site of the hearing, you could get a clot forming, uh, from from the stenosis and then migrating distantly to cause a distal stroke on then. Also, the stenosis can be so severe that blood flow is actually reduced on. Compared to this, the brain tissue causing a stroke to the lack of blood flow due to the narrowing itself as we talked about the there is a risk of stroke, and it could be kind of pretty variable, depending on where it is and how narratives if if it is found without a stroke, meaning it's asymptomatic. The risk of stroke is thought to be relatively low, from 0 to 3.5% once it actually causes a stroke. Uh, the risk is one is actually symptomatic. The risk of stroke is relatively high and could be up to 30 40%. And as you can see on some of these numbers here, depending on the vessel, it could be anywhere from 19 to 34% risk of stroke, depending on how narrow it is and what the intracranial collateral circulation is for that particular patient. One question we get does it change? If we, uh, if we treated aggressively, does it get better? Does it get worse? What happens with these lesions on their We have several studies here suggesting that they actually are are a dynamic process. One study showed that when you use aspirin ah, and Selassie's all which are anti thrum biotic medications, there was a lower risk of progression in the aspirin. Selassie's all group versus the aspirin alone group. Another study showed with observation that about 20% of patients, uh, the narrowing got, uh, the narrowing improved with aggressive medical management of about 40% progressive, about 40% remained unchanged. So the vast majority of patients with intracranial stenosis either remain the same or progress despite aggressive medical therapy, which can then increase your risk of stroke in the future. This is based on some early studies thes air Some of the earlier studies back several years ago on you can see here that most of them have pretty severe stenosis anywhere from 63 to 82% on the recurrent stroke rate can be anywhere up to 14 or 15%. So, again, a high risk lesion in these patients for causing future stroke. What has led to was a random. My large randomized trial called Sampras on this came out several years ago, and this was testing, uh uh, stenting for intracranial stenting, angioplasty and stenting for these lesions versus aggressive medical management and which one was better in preventing strokes in the future. And they had to have a high a high degree of stenosis anywhere from 70 to 99% on again. It was aggressive medical management, which is aspirin, Plavix, Staten of plus or minus intracranial stenting. And what they found was that the stroke rate was actually much higher than expected for the stenting group. They estimated to be approximately 10 to 13% and based on prior studies and, they found, is actually closer to 15% on the the stroke rate for the medical management group was actually much lower than expected, about 6% versus what they expected from prior studies to be about 20%. And so the study was stopped early. It was it was determined that for intracranial stenosis, aggressive medical management was preferable. Thio intracranial, uh, angioplasty and stenting for preventing strokes in these in this patient population, looking further, looking a little bit closer into the end of the study itself. Uh, it is, uh, it was determined that a lot of the strokes in the standard Group were not necessarily from the revascularization or improvement of the stenosis itself. It was from the procedure. They found that a lot of strokes were due to what were called perforated inclusions. Then you can see on the diagram on the page. Here, per freighters are small branches arising from the main trunk of a vessel. So if there was a narrowing in that yellow circle, you can imagine if there's a balloon inflated and a stent placed some of those little little branches off to the side could be blocked by the stent itself. So it wasn't a stroke from, uh, the stent opening up the artery in a distal territory. It was direct blockage of these small perforating branches by the device itself. Some of the strokes were also perforations or ruptures during the procedure, meaning a wire or another part of the device caused a hole in the artery, causing bleeding up in the brain. And again, it's not necessarily due to the stroke was not due to, uh, the stent itself. It was due to a procedural complication so hard to attribute that to the stent itself. In stroke is causing the strokes. So what do we learn from the study? Even though it was not perfectly designed, we realized just how good medical management is these days. How effective Aspirin, Plavix, Staten diabetes control, tobacco control, How effective that is in preventing strokes in the future. It also demonstrated the importance of, uh, Perry procedural intra procedural factors in this In these patient populations, we found that we need Thio B'more aggressive with our anti platelet testing to see if patients respond to Plavix. How well they're Staten reduces their cholesterol. We realized how important blood pressure control is in these patients on how important it is to watch and observe the stents to make sure they stay open and little emboli are not forming and going just on causing strokes. This led thio new indication for intracranial angioplasty and sending in patients with intracranial stenosis. Uh, the most important, which is circled here on what the FDA determines a Z Appropriate use for these devices is the patient has to have two strokes despite medical therapy. Then they qualify for intracranial angioplasty and stenting. Otherwise, they need to have severe stenosis. 17 99%. It needs to be done approximately one week after the event. For this to be a new indicated procedure for integration and for intracranial stenosis. Now there was some there some more recent data. Now this is a study called We've on is ah, a registry of angina, angioplasty and stenting for intracranial stenosis. Four patients that meet the new FDA criteria. Uh, they also looked at these other factors that I mentioned the pair of procedural into procedural care. How well does the patient respond to Plavix? How long have they been on their medications? When was their stroke? Was it more than seven days ago? So these patients in this registry met all of the current FDA criteria on what they and here's the study. So again, they need to have severe stenosis. Uh, they were greater than one week from their event. Uh, they tested anti platelets when possible. On what they found was that the stroke rate in this in this patient population when they met the new FDA criteria was extremely low, approximately 2.5%. Now, again comparing it to the Sampras it was 15%. When the patients were treated with the new labeling from the FDA, the stroke rate was very low, approximately 2.6%. Uh, the we've patients were then followed out to one year on, observed again for their Now they're long term stroke rate and what they found, as you can see in the upper left, Sampras is on top. The stroke rate was 20%. Uh, the sample, the sample aggressive medical management was 12% and in the woven it was down to 8% on again compared to samples on the right slide. There, you can see that the long term 1 to 12 months stroke rate was much lower. Uh, in the we've and woven patient population compared to Sampras on again. What this suggests is that when the patients are selected carefully and they are treated appropriately with their medical management and there followed, and we are sure that there responding to the anti robotic medications were following their blood pressure closely in the I. C. U. Uh, the stroke rate from an angioplasty stenting for severe symptomatic intracranial stenosis is actually very, very low. So one of the current recommendations, uh, what we found is this is from the most up to date American Heart Association guidelines. And to summarize this slide, it's basically aggressive medical management first aspirin, Plavix, blood pressure control, cholesterol control, stopping smoking. These are all the first line recommendations for preventing strokes with patients with integrated intracranial stenosis. We found that the aggressive medical management has been determined to be aspirin and Plavix. Uh, not some of the other medications as we're not. We don't have enough data with other medications. Likes Alaska's all or some of the new or to be three A inhibitors. It's aggressive. Blood pressure control with systolic pressure is less than 1 40 Um, when patients fail these medical therapies and have strokes. Despite these aggressive medical therapies. That's when we start to talk about integration, angioplasty and stenting or revascularization of the intracranial circulation. So, in summary for thes patients, uh, again, first line is aggressive medical management. Aspirin, Plavix, Staten tobacco control, diabetes control on If somebody should have a stroke. Despite this aggressive medical management, and they have severe stenosis of 70 to 99% this is when we start talking about intracranial angioplasty and stenting for these patients for stroke stroke prevention. This is the guidance from the current neuro interventional societies. Again, it's aspirin and clopidogrel for three months, then aspirin or Plavix alone on. If they fail those medications, well, then consider angioplasty and stenting. Uh, they specify that we don't. We typically do not use the coronary balloons, and I'll talk about I'll show an example of that in a minute. Uh, this is for the integration, uh, stenosis system of the wingspan and gateways, uh, devices. So when do we stent? Asai said. They need to have a severe stenosis. A greater than 70%. It needs to be symptomatic, meaning it's caused a stroke. Thes symptoms have to be in the territory reparable to that vessel. Uh, they need to have failed maximum medical therapy. And again, that's considered to be aspirin, Plavix, Staten and aggressive lifestyle Risk factor modification on again. It should be done by experienced physicians. The weave and woven data demonstrated that though the when the stents were placed by physicians that have done many of these procedures, the stroke rate was very low, almost zero. And the complications occurred typically, and those that were less experienced. So again, you want somebody that's done. Ah, fair number of these procedures, uh, doing this, uh, doing this on the patient population. So some case examples thistles the room that way, Use as you can see here. The machine has an anterior and lateral x ray system, and that's it gives us a new AP and a lateral picture of the blood vessels. As you can see on the side of your screen, we can access the vessels either in the federal artery, the radial artery, the break Your larder even directly punctured the carotid artery with the goal of eventually getting our devices up into the head. As you can see here, we use different shaped catheters to allow for a very variance in the anatomy. But one way or another, we try to get there are devices up into the vessels up in the brain. This is a typical system. As you can see, it's minimally invasive with just a puncture in the femoral artery. In this particular patient, you could see the sheath in the federal already with a catheter on a heparin ized flush to prevent clots from forming in the devices themselves. And then you can barely see the micro catheter third device there, which is what we used to go up into the brain itself. And these device these catheters, or less than the size of angel hair, spaghetti and the wires that we used to get up there are about 14 1 thousands of an inch. So a very small system minimally invasive on this is how we get our devices up into the brain to treat these patients. This is the difference between a neuro balloon and a coronary balloon. On the bottom, you can see a typical coronary balloon, which is a stent mounted on a balloon in a catheter itself. So everything is 11 single system. The benefit is there's not a lot of moving parts and a lot of exchanging devices out. The downside is these devices air relatively stiff because the balloon and the stent are all in one catheter. It's harder to navigate these devices because everything is on one. Katherine makes them a little stiff and tough to get through very torturously or, ah, twisted vessels. The neural system is list is above, and you can see that it's a separate balloon and stent on. So it makes the device a little bit more navigable and softer and easier to take these tight turns that we have up in the brain. This is a patient that came in that had a event approximately one month prior on. He was down on aspirin, Plavix and Staten, and he came in with new symptoms in the right side of the brain. And you could see the stroke there in the right EMC territory. This is his Mara, and you can see in the circled area there is a short segment of severe stenosis, So at this point, he has failed medical therapy. This is his second event on, so we took him for revascularization with angioplasty and sending you could see the angiogram on just how tight the narrowing is. This picture shows a small wire that we navigate through the vessel. You could barely see the wire because it is so small there's Here's the balloon that's inflated on. You could see the small shadow there. The balloon is about two millimeters, and then once the stent is in place now, you can see that the stenosis is much improved and the blood flow is much improved. And he ended up doing very well without any any further strokes. Another patient who was admitted with imbalance in vertigo, his M R. I showed a Sarah Beller stroke. He was started on aggressive medical therapy. He was getting ready to go to rehab after some physical therapy in the hospital had new symptoms. And now on the Emory, you could see the new strokes and the left side of cerebellum eso. Now he's had strokes on both sides of the cerebellum in the post recirculation. Despite aggressive medical therapy, the Mara demonstrated that his one vertebral already was completely included. A zit entered the skull. The other vertebral already had a high grade stenosis, and he had no collateral circulation from the anterior circulation Azi had no posterior communicating artery, so he had an isolated poster circulation with a severe stenosis in the one blood vessel that was feeding the poster part of his brain. So here's an angiogram, and you can see in the circled area this high degree, this high degree of stenosis in the vertebral artery on again. This is the only blood vessel feeding the brain stem and the posterior circulation. So again, here he is with the wire through the stenosis. And then the balloon is inflated to improve the stenosis and break up the plaque. And here it is, with the stent in place. And now you can see the stenosis is resolved without any residual nearing on. But he had no further strokes after this procedure. Another typical patient, Ah, 69 year old person with right EMC symptoms. You could see the high degree of stenosis in that right middle super artery. Uh, they When they first came in, they were already on aspirin, Plavix and Staten and aggressive medical therapy of all their vascular risk factors. Despite this, they had another stroke. And so we felt this was inappropriate patient to treat with angioplasty and stenting. Here it is with the wire across again. You could barely see the wire because of the size. And here it is, once the stent in place without any residual stenosis on again. The procedure went well, and patient had no further strokes after this procedure. Another patient this time with left symptoms and you can see the severe stenosis at the origin of the left. Medals were artery with a balloon in place. And then when the stent in place and no residual stenosis on again, the patient did well, without any further strokes. Sometimes we have to place these patients, these stents acutely. Most of these patients, the stents placed one week after the event in order to prevent another stroke. This patient came in with right symptoms on. We took him for a throne. Beckham. You can see the cat scan there and the cat scan and again without any large stroke. But on the cat scan angiogram, you can see a nick luge in of the right middle cerebral artery. When we took him for, uh, to the angiogram, we, uh we saw that the right middle school already was included at its origin. What the some of these other pictures demonstrate is that the right EMC territories filling late from collateral circulation? Sometimes this could be a sign of an intracranial stenosis, as thes collaterals can take time to develop. So if somebody if this is an acute occlusion, sometimes these collaterals have not had a chance to develop. If somebody has a stenosis that's been there for a while, these vessels have developed and there's good collateral circulation of the territory. So this was suggestive of an underlying intracranial stenosis we went in with are thrown back into devices and we were able to open up the device, open up the vessel with the stent retriever. However, every time we watched, it would then eventually shut down again, consistent within underlying stenosis. We then, uh and here's an example. Here it is. After the device is deployed, we watched her for a few minutes and you can see it start to re include and again again eventually progresses to complete re inclusion. We tried angioplasty as well. We put a small balloon, their inflated the balloon to try to open up the vessel. Every time we did that, though, and again the vessel re included. So we decided that we needed to place a stent, uh, to maintain the vessel. Uh, Peyton C. In this case, we had to use a coronary balloon because we did not have, uh, the appropriately sized a wingspan device at this time and again, you can see the wire deployed over the area of stenosis. We then were able to navigate the stent, the balloon mounted stent in the area of stenosis. And here it is, after deploying in the balloon, and you could see no residual narrowing in the area of the, uh, right middle cerebral artery. Here's his memory. The next day, with minimal stroke on the right, and he went home two days later. Completely intact. Aunt has remained stable as an outpatient. Sometimes we can get intracranial stenosis, not from anthros grosses, but from something called a dissection on. You can see on the picture. Here dissection is an injury to the wall of the artery. The inner lining of the artery peels away and eventually can provide can eventually become so severe that at the aluminum, the vessel is actually compromised like an intracranial stenosis. This is it. This is the case of a young patient who was at the gym, was exerting themselves and then came home with headaches, neck pain and die. A free sis went to an outside hospital. And when somebody complains of neck pain and sweating and diaries is the first thing they worry about his meningitis, he had a lumbar puncture which did not demonstrate meningitis and then eventually had progression of his neurologic symptoms consistent with a basilar artery inclusion. They did a CT angiogram which demonstrated vertebral artery dissections as well as a basilar artery occlusion. So he was transferred to our facility for intervention. So here's the first angiogram and you can see the dissection in the vertebral artery on the right. With this is outside the brain. But you can see you from both vertebral artery angiograms in the middle and on the side that there is no intracranial flow to the basilar artery on. So now you can see that the basilar artery has now been completely revascularization. There is now a good flow in the poster circulation. As we pulled our catheter out, we could see that there is a severe dissection of this vertebral artery and you could see the narrowing here on these pictures with the lack of flow up into the basilar artery. So what we decided we had to put a stent in this vessel is well, to treat this narrowing. Uh, we use this pipeline what's called a pipeline device, which is a flow diverting device designed for the intracranial vessels and very navigable and very good at taking these tight turns. And you can see here after deployment of the device, there is complete revascularization of the integrated circulation without any residual narrowing. And this patient ended up doing very well. Finally, we have one more dissection. This is a young woman who was in a motor vehicle accident on you can see here that she had a severe dissection and aneurysm due to the dissection from her trauma. Initially, she had multiple fractures, required chest tubes, had a skull fracture on, was stabilized in the queue for two weeks. Once she was more stable. We felt it was safe to address this dissection in stenosis and aneurysm. And so we started her own blood thinning medications on Took it to the cath lab with a attempt. Thio, fix this stenosis and dissection. We place the flow diverting stent across the area of stenosis and dissection to remodel the vessel and improve the flow and caliber the vessel. This is the angiogram immediately after the device was placed. Now you can see that there's the vessel has been completely remodeled with without any residual narrowing or stenosis from the dissection. And then six months later, now you can see that the stenosis and dissection are completely resolved on. She ended up doing very well on so in summary, again for intracranial stenosis is a common cause of stroke. But what we know now is that based on data, we need to do aggressive medical management first Aspirin, Plavix, statin lifestyle modifications on Should somebody developed a new stroke after implementation of these medications, then we will consider integrating angioplasty and stenting. Thank you very much for listening to this video. I'd like to thank Dr Zadeh in the rest of the Department of Neurosurgery for the opportunity. Thio present this to you. Thank you
