Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results

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Object. A retrospective analysis of a 9-year experience with balloon angioplasty for intracranial atherosclerotic stenosis was undertaken with the goals of illustrating development of a safe technique for treatment of intracranial atherosclerotic disease and reporting the immediate results in this series of patients.

Methods. Three distinct periods are defined, based on the technique used. In the early period, in which eight patients were treated, the angioplasty balloon size approximated the vessel size, but was always smaller. Angioplasty was moderately rapid and brief (15–30 seconds). Clinical improvement occurred in seven (87.5%) of eight patients, dissection without consequence occurred in four (50%) of eight, and residual stenosis greater than 50% was found in three (37.5%) of eight. No neurological complications occurred.

In the middle period, in which 12 patients were treated, the balloon size approximated the vessel size, but oversizing by up to 0.25 mm was permitted. Angioplasty was extremely rapid and brief. Angiographically visible dissection occurred in nine (75%) of 12 patients, necessitating urokinase infusion in five (41.7%) of 12 and producing abrupt occlusion in one (8.3%) of 12, resulting in death. Occlusion secondary to the recrossing of the lesion occurred in one (8.3%) of 12, resulting in stroke. Good outcome was eventually achieved in 10 (83.3%) of 12.

In the current period, in which 50 patients have been treated, the balloon is always undersized and inflation is extremely slow (several minutes). Dissection occurred in seven (14%) of 50 patients, necessitating fibrinolysis in two of 50 (4%, both uneventful) and producing no abrupt occlusion or stroke. Residual stenosis greater than 50% occurred in eight (16%) of 50, with no stenosis greater than 70%. Late restenosis occurred in four (9%) of 44 and successful repeated angioplasty was performed in all four. One guidewire vessel perforation occurred (2%), resulting in the patient's death. Good angiographic and short-term clinical outcome was achieved in the other 49 patients (98%).

Conclusions. Extremely slow balloon inflation combined with balloon undersizing results in decreased intimal damage, decreased acute platelet/thrombus deposition, and decreased acute closure. This technique sometimes yields suboptimal angiographic results but achieves the clinical goal safely. Intracranial angioplasty can be safely performed using this technique and modern equipment.

Article Information

Address reprint requests to: J. J. Connors III, M.D., Department of Radiology, INOVA Fairfax Hospital, 3300 Gallows Road, Falls Church, Virginia 22046. email: budmancon@aol.com.

© AANS, except where prohibited by US copyright law.

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    Angiographic studies demonstrating postangioplasty malignant thrombosis. A and B: Posteroanterior (PA) (A) and lateral (B) left common carotid artery (CCA) angiograms obtained in a 51-year-old man who had symptoms typical of stenosis of the distal ICA or MCA. These included episodic weakness, clumsiness, and numbness of the hand with occasional speech difficulty. The angiogram reveals severe hemodynamic abnormality; note that the superficial temporal artery (arrows) reaches the crown of the head long before intracranial vessels are even perfusing their own territory. C: A magnified view of the focal stenosis after 250,000 U urokinase was infused over 1 hour. This study infusion was given to assess the possibility of thrombus superimposed on the plaque and reveals that the stenotic vessel diameter remains much smaller than 1 mm. D and E: Angioplasty was performed using a 2-mm STEALTH balloon. After the angioplasty was performed, the occluding wire was left in the vessel across the stenosis while the catheter was withdrawn slightly (note the markers on the balloon, short arrows). The angioplasty result appears to be satisfactory (long arrows). Note the excellent antegrade intracranial flow on the lateral view. F: Continued observation was maintained periodically until this image was obtained. The lateral angiogram (obtained 27 minutes after angioplasty and 22 minutes after the studies depicted in D and E) demonstrates that the ICA is now completely occluded (arrows). It was at this time that the patient began to experience some neurological difficulty, a point at which most patients would be in the recovery room. G: Four minutes after the study depicted in F, infusion of urokinase was begun, and after a bolus of approximately 20,000 U had been slowly administered the vessel was again patent. Abundant thrombus is still evident at the angioplasty site (arrow). H and I: In PA and lateral views obtained 1 hour and 25 minutes after the study depicted in G, and after a total of 610,000 U of urokinase had been infused, the vessel and angioplasty site are revealed to be cleared (arrows). Subsequent observation of the site revealed no further evidence of malignant thrombosis, and the patient was neurologically intact.

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    Angiographic studies obtained in a 62-year-old man who had periodic episodes of dizziness associated with falling to the right. Over the previous 3 years he had developed visual difficulties for which he required a magnifying glass to read and which made him unable to watch television. His cardiologist diagnosed a third-degree heart block; the episodic neurological symptoms (dizziness and falling) were ascribed to cardiogenic syncope. A transvenous pacemaker was placed, but he achieved no relief from his symptoms. A: Cerebral angiogram revealing a threadlike remnant of the left VA at the atlantooccipital junction (arrow), a typical location for stenosis (as well as idiopathic dissections). The right VA was occluded. B: Follow-up left VA angiogram obtained after angioplasty of this lesion demonstrating an excellent angiographic result (long arrow) with resultant resolution of his episodic dizziness and ataxia. The angiogram demonstrates excellent posterior fossa perfusion, but extremely poor perfusion of the left occipital lobe (asterisk) beyond the threadlike origin of the left PCA. No true infarct was visible on computerized tomography scanning (repeat magnetic resonance imaging could not be performed because of the patient's pacemaker). His vision was very poor even with his glasses (he could not read a clock from across the room), but his visual fields were full to confrontation. The decision was made to perform angioplasty to treat the PCA stenosis at a later date. C: Preangioplasty appearance of the left PCA origin stenosis (long white arrow). The normal portion of the vessel distal to the lesion measures only 1.6 mm, but was successfully treated with angioplasty. D and E: Postangioplasty appearance at 9-month follow up. The appearance of the origin of the PCA is good (white arrows, D). There is now bilaterally symmetrical perfusion of the occipital lobes (arrows, E). The day after the angioplasty of the origin of the left PCA, the patient commented that he could watch television for the first time in 3 years and he now reads without glasses.

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    Angiographic studies obtained in a 53-year-old man who presented to the emergency room with acute discoordination, ataxia, dysarthria, and dizziness. Computerized tomography studies were unremarkable. A: Admission angiogram (PA view of the left CCA injection) demonstrating abnormal flow not only to the ipsilateral PCA, but also to the BA through a very small posterior communicating artery (PCoA) (long thin arrow). Indeed, there is flow into both superior cerebellar arteries (small arrows) as well as inferiorly into the mid-BA (large arrow), a most abnormal distribution through such a small PCoA. This implies essentially no normal antegrade perfusion of the posterior fossa. B: No right VA is present; PA view of the left VA injection reveals an apparent occlusion of the distal VA, just past the origin of the PICA (large arrow). There is reconstitution of the BA via anastomoses with the left anterior inferior cerebellar artery (AICA). Note filling of the opposite (right) AICA (small arrow). The patient was placed on intravenously administered heparin. No angioplasty was desired at this time. C: Repeated angiographic study obtained after 1 week of intravenous heparin administration revealing that the left VA has opened enough that angioplasty was thought to be unnecessary (arrow). The size of the vessel is surprisingly good and the flow is excellent. Note the retrograde flow into the right VA to its PICA (confirming proximal occlusion of this vessel), and the absence of a right PCA (which filled via the right PCoA). Because of the apparent reversal of the pathological narrowing, the patient received warfarin anticoagulation therapy and was scheduled to be followed in clinic. D: The patient presented on an emergency basis 3 months later with recurrent severe ataxia and dysarthria, despite adequate response to anticoagulation therapy. After reinstitution of heparinization, a repeated PA left VA angiogram reveals a very small, but still patent distal VA. Note that the left PCA is no longer filled because of the poor hemodynamics. Angioplasty was now considered necessary due to the nearly catastrophic failure of medical therapy. Because of the changing nature of this lesion, an unknown amount of thrombus was suspected and the procedure was delayed for 5 days, during which time the patient was maintained on intravenously administered heparin. E: Angiogram obtained 5 days after the study depicted in D. Due to the possibility that some of the continued narrowing was caused by additional thrombus, an infusion over approximately 25 minutes of 100,000 U urokinase was administered. This resulted in a smooth but very tight lumen. Note the continued absence of the left PCA because of hemodynamic insufficiency. F: Left VA angiogram obtained after angioplasty revealing an excellent result with good hemodynamics and no evidence of vascular damage from angioplasty. G: Angiogram obtained 1 hour postangioplasty, following our usual routine of continued observation of the angioplasty site, exhibiting some early narrowing and vessel wall irregularity (arrow), which was thought to be due to platelet aggregation. This was not believed to warrant any intervention, but rather continued observation. No further progression was seen and the procedure was terminated. H: Follow-up angiographic study obtained 9 months after the procedure revealing the angioplasty site to be remodeled; it is widely patent with excellent flow. The patient has remained clinically stable for 5 years.

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