Portal de Periódicos da CAPES

Advances in Stroke

2013; Lippincott Williams & Wilkins; Volume: 44; Issue: 2 Linguagem: Inglês

10.1161/strokeaha.111.000385

1524-4628

Giuseppe Lanzino, Anthony M. Burrows, Michael Tymianski,

Acute Ischemic Stroke Management

HomeStrokeVol. 44, No. 2Advances in Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBAdvances in StrokeVascular Neurosurgery Giuseppe Lanzino, MD, Anthony M. Burrows, MD and Michael Tymianski, MD, PhD Giuseppe LanzinoGiuseppe Lanzino From the Department of Neurologic Surgery (G.L., A.M.B.) and Department of Radiology (G.L.), Mayo Clinic, Rochester, MN; and Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada (M.T.). , Anthony M. BurrowsAnthony M. Burrows From the Department of Neurologic Surgery (G.L., A.M.B.) and Department of Radiology (G.L.), Mayo Clinic, Rochester, MN; and Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada (M.T.). and Michael TymianskiMichael Tymianski From the Department of Neurologic Surgery (G.L., A.M.B.) and Department of Radiology (G.L.), Mayo Clinic, Rochester, MN; and Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada (M.T.). Originally published15 Jan 2013https://doi.org/10.1161/STROKEAHA.111.000385Stroke. 2013;44:316–317Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 IntroductionThe indications for microsurgery in cerebrovascular pathology have been placed under increased scrutiny, given the continuous refinement of endovascular techniques. Several recent randomized studies and subgroup analyses of concluded studies have been particularly illuminating in this sense and will be the primary focus of this brief review.Extracranial Carotid StenosisThe Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) has shown that the risk of perioperative stroke is slightly higher after carotid artery stenting (CAS) than after carotid endarterectomy (CEA), whereas the reverse is true for the risk of periprocedural myocardial infarction.1 Over the past year, the CREST investigators have also reported the results of some prespecified and some ad hoc subgroup analyses. Earlier trials of CAS versus CEA had suggested higher risk of restenosis after endovascular treatment of carotid stenosis compared with CEA. However, in CREST after 2 years, the incidence of restenosis >70% or occlusion was similar in the CAS (6%) and the CEA (6.3%) groups, suggesting that restenosis may not be a major concern if endovascular treatment is contemplated.2 Female sex, diabetes mellitus, and dyslipidemia were associated with higher risk of restenosis in both groups.2 Smoking increased the risk of restenosis in patients undergoing CEA but not after stenting.2 Subgroup analysis by age confirmed that increasing age is associated with a higher risk of periprocedural stroke after CAS but did not affect the risk profile in patients undergoing CEA.3 In the CREST group, there were only minor differences in healthcare costs and quality-adjusted life expectancy between CAS and CEA, which contradicted early studies that had suggested higher costs associated with CAS.4Symptomatic Intracranial Stenosis/OcclusionThe past 2 decades had witnessed a trend toward more aggressive invasive treatment of patients with symptomatic intracranial stenosis. However, completion of the Carotid Occlusion Surgery Study (COSS)5 and the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMPPRIS)6 has shown that neither surgical bypass5 nor angioplasty and stenting6 are better than maximal medical therapy in preventing future ipsilateral ischemic events in patients with symptomatic internal carotid artery occlusion and intracranial stenosis, respectively. In both studies, the lack of a positive effect after invasive therapy was related to both a higher (than expected) periprocedural complication rate than anticipated with invasive treatment6,7 and a lower incidence of end point events in patients treated with maximal medical therapy, including statins and antihypertensives. Predictably, publication of these trials has also triggered wide criticism of the studies' methodology, inclusion criteria, and center selection.8,9 Nevertheless, these studies have had an impact in reducing the number of interventions done for symptomatic intracranial stenosis in North America.Intracranial AneurysmsThe debate regarding the safest and most effective therapeutic strategy in patients with intracranial aneurysms has continued with refinements of endovascular techniques. The International Subarachnoid Aneurysm Trial (ISAT) study, completed in 2002, changed the practice for many patients with ruptured aneurysms.10 However, several issues remained unanswered by that landmark trial. A possible recruitment bias among ISAT patients was raised by some critics, given that 9559 patients were screened and only 2143 included. The Clinical and Anatomic Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY) registry was initiated to address this criticism and to address the applicability of the ISAT results to multiple endovascular centers.11 Among this registry, 405 consecutive patients with subarachnoid hemorrhage were treated with coil embolization at 19 French centers. Six-month mortality and morbidity were similar to ISAT, with 23.3% of all patients scoring ≥3 on the modified Rankin Scale at 3 to 6 months, despite 30% of patients being admitted in grade IV/V. Further concerns were raised regarding the applicability of ISAT results to North American centers with reputedly more subspecialized cerebrovascular surgeons. In response to the above concerns, surgeons at the Barrow Neurological Institute in Phoenix, Arizona, launched the Barrow Ruptured Aneurysm Trial (BRAT) in 2002. The results of this landmark study were recently published.12 The BRAT investigators assigned every patient with subarachnoid hemorrhage to either endovascular therapy or surgical clipping in an alternating fashion to more accurately model clinical realities. As a consequence of this design, a large number of patients allocated to endovascular treatment crossed over to surgical treatment because patients could be enrolled regardless of whether the aneurysm was amenable to both treatment modalities. Therefore, aneurysms that could not be safely treated with coiling for technical reasons (ie, very small aneurysms) or clinical considerations (ie, aneurysms associated with intraparenchymal hematomas necessitating surgical evacuation) were still assigned to embolization. Despite a high rate of crossover, the BRAT study confirmed previous ISAT conclusions: outcomes at 1 year were better after coil embolization than after surgical clipping. The proportion of patients experiencing a poor outcome (defined by a modified Rankin score >2) was 33.7% in the surgical group versus 23.2% ([P=0.02], intention-to-treat analysis) in the endovascular group. As-treated analysis yielded similar results, with 33.9% patients in the surgical group and 20.4% in the endovascular group experiencing a poor outcome at 1 year (P=0.01). Overall, the BRAT study confirmed the ISAT conclusions, while at the same time stressing that surgery continues to be a valid and important option for selected patients with ruptured intracranial aneurysms. Several considerations that include patient-related, aneurysm-related factors and local logistics and practice patterns have a very important role in deciding the best therapeutic strategy in a patient with a ruptured intracranial aneurysm.Arteriovenous MalformationsThe optimal management strategy in patients with intracranial parenchymal arteriovenous malformations continues to be controversial. An update of the Finnish database suggested a non-negligible risk of bleeding in patients with untreated high-grade AVMs.13 However, patients considered in that study spanned a very long time interval, presented mostly with hemorrhage, and often harbored AVMs considered not amenable to invasive treatment because of the risks involved. The ongoing A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) study compares outcomes of intervention versus best conservative therapy for unruptured AVMs considered amenable to invasive treatment.14 In a recent update, 193 of 389 eligible among 1294 screened patients were randomized by March 2012.14 Results of this study are eagerly awaited but should be interpreted with the caveat that important methodological flaws may be present.15Josephson et al16 investigated the risk of seizures after either invasive treatment or conservative management of AVMs. No significant difference in the 5-year risk of unprovoked seizure was observed between the invasive treatment group and the conservatively managed group, irrespective of AVM obliteration status. For patients with an AVM who presented with seizures but no hemorrhage, no difference in seizure recurrence was observed during follow-up between patients treated invasively (39 patients) and those treated medically (21 patients).DisclosuresG. Lanzino is a consultant for ev3/Covidien. The other authors have no conflicts to report.FootnotesCorrespondence to Giuseppe Lanzino, MD, Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. E-mail [email protected]References1. Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis.N Engl J Med. 2010; 363:11–23.CrossrefMedlineGoogle Scholar2. Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, et al; CREST Investigators. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial.Lancet Neurol. 2012; 11:755–763.CrossrefMedlineGoogle Scholar3. Voeks JH, Howard G, Roubin GS, Malas MB, Cohen DJ, Sternbergh WC, et al; CREST Investigators. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial.Stroke. 2011; 42:3484–3490.LinkGoogle Scholar4. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD, et al; CREST Investigators. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).Stroke. 2012; 43:2408–2416.LinkGoogle Scholar5. Powers WJ, Clarke WR, Grubb RL, Videen TO, Adams HP, Derdeyn CP; COSS Investigators. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial.JAMA. 2011; 306:1983–1992.CrossrefMedlineGoogle Scholar6. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al; SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis.N Engl J Med. 2011; 365:993–1003.CrossrefMedlineGoogle Scholar7. Grubb RL, Powers WJ, Clarke WR, Videen TO, Adams HP, Derdeyn CP. Surgical results of the carotid occlusion surgery study.J Neurosurg. 2012.Google Scholar8. Amin-Hanjani S, Barker FG, Charbel FT, Connolly ES, Morcos JJ, Thompson BG; Cerebrovascular Section of the American Association of Neurological Surgeons; Congress of Neurological Surgeons. Extracranial-intracranial bypass for stroke-is this the end of the line or a bump in the road?Neurosurgery. 2012; 71:557–561.CrossrefMedlineGoogle Scholar9. Abou-Chebl A, Steinmetz H. Critique of "Stenting versus aggressive medical therapy for intracranial arterial stenosis" by Chimowitz et al in the new England Journal of Medicine.Stroke. 2012; 43:616–620.LinkGoogle Scholar10. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.Lancet. 2002; 360:1267–1274.CrossrefMedlineGoogle Scholar11. Cognard C, Pierot L, Anxionnat R, Ricolfi F; Clarity Study Group. Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: clinical results of the Clarity GDC study.Neurosurgery. 2011; 69:837–841; discussion 842.CrossrefMedlineGoogle Scholar12. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. The Barrow Ruptured Aneurysm Trial.J Neurosurg. 2012; 116:135–144.CrossrefMedlineGoogle Scholar13. Laakso A, Dashti R, Juvela S, Isarakul P, Niemelä M, Hernesniemi J. Risk of hemorrhage in patients with untreated Spetzler-Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients.Neurosurgery. 2011; 68:372–377; discussion 378.CrossrefMedlineGoogle Scholar14. Mohr JP, Moskowitz AJ, Parides M, Stapf C, Young WL. Hull down on the horizon: a Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA) Trial.Stroke. 2012; 43:1744–1745.LinkGoogle Scholar15. Cockroft KM, Jayaraman MV, Amin-Hanjani S, Derdeyn CP, McDougall CG, Wilson JA. A perfect storm: how a randomized trial of unruptured brain arteriovenous malformations' (ARUBA's) trial design challenges notions of external validity.Stroke. 2012; 43:1979–1981.LinkGoogle Scholar16. Josephson CB, Bhattacharya JJ, Counsell CE, Papanastassiou V, Ritchie V, Roberts R, et al; Scottish Audit of Intracranial Vascular Malformations (SAIVMs) steering committee and collaborators. Seizure risk with AVM treatment or conservative management: prospective, population-based study.Neurology. 2012; 79:500–507.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Mitroshina E, Mishchenko T, Loginova M, Tarabykin V and Vedunova M (2020) Identification of Kinome Representatives with Neuroprotective Activity, Neurochemical Journal, 10.1134/S1819712420040133, 14:4, (394-407), Online publication date: 1-Oct-2020. Yue Q, Zhu W, Gu Y, Xu B, Lang L, Song J, Cai J, Xu G, Chen L and Mao Y (2014) Motor Evoked Potential Monitoring During Surgery of Middle Cerebral Artery Aneurysms: A Cohort Study, World Neurosurgery, 10.1016/j.wneu.2014.09.004, 82:6, (1091-1099), Online publication date: 1-Dec-2014. Mitroshina E, Loginova M, Savyuk M, Krivonosov M, Mishchenko T, Tarabykin V, Ivanchenko M and Vedunova M (2021) Neuroprotective Effect of Kinase Inhibition in Ischemic Factor Modeling In Vitro, International Journal of Molecular Sciences, 10.3390/ijms22041885, 22:4, (1885) Mitroshina E, Loginova M, Yarkov R, Urazov M, Novozhilova M, Krivonosov M, Ivanchenko M and Vedunova M (2022) Inhibition of Neuronal Necroptosis Mediated by RIPK1 Provides Neuroprotective Effects on Hypoxia and Ischemia In Vitro and In Vivo, International Journal of Molecular Sciences, 10.3390/ijms23020735, 23:2, (735) February 2013Vol 44, Issue 2 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.000385PMID: 23321447 Manuscript receivedDecember 4, 2012Manuscript acceptedDecember 20, 2012Originally publishedJanuary 15, 2013 Keywordsintracranial stenosiscarotid stenosisextra-intracranial bypassarteriovenous malformationsintracranial aneurysmscerebrovascular surgeryPDF download Advertisement SubjectsCerebrovascular Disease/Stroke