Transluminal Angioplasty and Stenting for Intracranial Vertebrobasilar Occlusive Lesions in Acute Stroke Patients

K. Imai; T. Mori; H. Izumoto; T. Kunieda; N. Takabatake; S. Yamamoto; M. Watanabe

doi:10.3174/ajnr.A0906

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Table 1:

OTDT/OTPT, preprocedural neurologic symptoms, and DWI/angiographic findings in the occlusion group

Patient/Sex/Age (y)	OTDT/OTPT (h)	Preprocedural Neurologic Symptoms	A-NIHSS/P-NIHSS	High Signal Intensity on DWI	Occluded Vessels^*
1/M/57	68/72	Deep coma, AR, OP, BP, QP	12/34	M, P, CER	lt.V4-pBA, rt.V1
2/M/72	31/48	Stupor, OP, BP, HP	8/21	M, CER, OL	lt.V4, rt.V1
3/M/63	1/3	Coma, AR, OP, BP, QP	29/29	P, CER	lt.V4, rt.V3
4/M/75	5/7	Somnolence, OP, BP, QP	17/17	P	lt.V4, rt.V3, pBA
5/F/62	8/10	Somnolence, BP, HP	12/12	P, CER	mBA
6/F/73	4/6	Deep coma, AR, OP, BP, QP	34/34	M, P, MB, CER	lt.V3, rt.V1
7/M/74	1/3	Deep coma, AR, OP, BP, QP	34/34	MB, CER	pBA
8/M/77	5/7	Stupor, AR, OP, BP, QP	22/22	P, CER, OL	lt.V4-pBA, rt.V2
9/M/84	9/11	Somnolence, BP, HP	3/15	P	mBA, lt.V4
10/F/74	3/5	Coma, AR, OP, BP, QP	30/30	P, OL	mBA
11/M/74	2/17	Deep coma, AR, OP, BP, QP	4/30	CER	lt.V4-pBA, rt.V2
12/M/63	7/9	Deep coma, AR, OP, BP, QP	35/35	P, CER	rt.V4, lt.V3
13/F/76	24/47	Stupor, AR, OP, BP, QP	6/27	P, CER, OL	lt.V4, rt.V4
14/F/81	12/36	Coma, AR, OP, BP, QP	4/32	P, MB, OL	mBA
15/F/71	4/47	Stupor, OP, BP, HP	7/20	P, CER	lt.V3, rt.V3
16/F/60	4/6	Deep coma, AR, OP, BP, QP	34/34	P	pBA

Note:—OTDT indicates onset-to-door time; OTPT, onset-to-the-procedure time; A-NIHSS, National Institutes of Health Stroke Scale score on admission; P-NIHSS, preprocedural National Institutes of Health Stroke Scale score; M (column 1), male; F, female; DWI, diffusion-weighted MR imaging performed immediately before the procedure; AR, ataxic respiration; OP, ophthalmoplegia; BP, bulbar palsy; QP, quadriparesis; HP, hemiparesis; M (column 5), medulla oblongata; P, pons; MB, midbrain; CER, cerebellum; OL, occipital lobe; lt., left-sided; rt., right-sided; V1, proximal extraosseous segment of the vertebral artery; V2, foraminal segment of the vertebral artery; V3, intra-extraspinal segment of the vertebral artery; V4, intradural segment of the VA; pBA, proximal basilar artery; mBA, middle basilar artery; dBA, distal basilar artery.
* This was diagnosed by angiography.

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Table 2:

OTDT/OTPT, preprocedural neurologic symptoms, and DWI/angiographic findings in the stenosis group

Patient/Sex/Age (y)	OTDT/OTPT	Preprocedural Neurologic Symptoms	A-NIHSS/P-NIHSS	High Signal Intensity on DWI	Stenotic Vessels^*	Occluded Vessels^*
17/M/77	24/27	Somnolence, OP, BP, HP	15/15	CER	lt.V4-pBA, rt.V4	None
18/M/65	2/96	BP, frequent drop attacks	2/1	OL	rt.V4-pBA	lt.V4
19/M/78	2/4	Deep coma, AR, OP, BP, QP	33/33	CER	dBA	rt.V2
20/M/59	4/72	Frequent drop attacks	4/0	None	lt.V1, lt.V3, mBA	None
21/M/75	6/120	OP, BP, frequent syncopal attacks	2/2	OL	pBA	lt.V3
22/M/70	2/168	OP, BP, frequent drop attacks	6/2	P	Lt.V4, rt.V4, mBA	None
23/F/82	24/140	BP, HP, frequent syncopal attacks	3/3	P	mBA	rt.V3
24/M/64	48/168	OP, frequent syncopal attacks	2/1	P	pBA	None
25/M/60	51/98	Stupor, OP, BP, QP	8/17	MB, CER	mBA	None
26/M/74	10/96	BP, frequent drop attacks	1/1	None	mBA	rt.V1
27/M/78	12/144	Stupor, OP, BP, HP	8/18	CER	lt. V1, mBA	rt.V1
28/M/66	2/168	OP, BP, HP	10/7	P	rt.V4-pBA	lt.V3

Note:—OTDT indicates onset-to-door time; OTPT, onset-to-the-procedure time; A-NIHSS, National Institutes of Health Stroke Scale score on admission; P-NIHSS, preprocedural National Institutes of Health Stroke Scale score; M (column 1), male; F, female; DWI, diffusion-weighted MR imaging performed immediately before the procedure; AR, ataxic respiration; OP, ophthalmoplegia; BP, bulbar palsy; QP, quadriparesis; HP, hemiparesis; P, pons; MB, midbrain; CER, cerebellum; OL, occipital lobe; lt., left-sided; rt., right-sided; V1, proximal extraosseous segment of the vertebral artery; V2, foraminal segment of the vertebral artery; V3, intraextraspinal segment of the vertebral artery; V4, intradural segment of the vertebral artery; pBA, proximal basilar artery; mBA, middle basilar artery; dBA, distal basilar artery.
* This was diagnosed by angiography.

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Table 3:

Methods of TAS and angiographic results in the occlusion group

Patient/Sex/Age (y)	No. of Used Stents	Dose of Urokinase^*	Preprocedure/Postprocedure TIMI^†	Prestenosis/Poststenosis (%)^‡	Technical Success	Procedural Dissections or Clots
1/M/57	3	0	0/3	100/10	Success	Yes
2/M/72	1	0	0/3	100/5	Success	Yes
3/M/63	3	0	0/3	100/30	Success	Yes
4/M/75	0	12	0/3	100/40	Success	No
5/F/62	0	24	0/0	100/100	Failure	NE
6/F/73	0	42	0/0	100/100	Failure	NE
7/M/74	0	0	0/3	100/45	Success	No
8/M/77	0	12	0/3	100/20	Success	No
9/M/84	1	0	0/3	100/10	Success	Yes
10/F/74	0	0	0/3	100/40	Success	No
11/M/74	1	0	0/0	100/100	Failure	Yes
12/M/63	0	0	0/3	100/10	Success	No
13/F/76	3	0	0/3	100/8	Success	Yes
14/F/81	0	0	0/3	100/10	Success	No
15/F/71	1	0	0/3	100/25	Success	Yes
16/F/60	0	0	0/3	100/20	Success	No

Note:—TAS indicates transluminal angioplasty and/or stenting; NE, no evaluation; M, male; F, female; TIMI, Thrombolysis in Myocardial Infarction.
* Data are ×10⁴ units.
† Grading with the TIMI definitions, 0 indicates no perfusion; 1, penetration without perfusion; 2, partial perfusion; and 3, complete perfusion.
‡ Preprocedural and postprocedural stenotic ratio was measured with the warfarin-aspirin symptomatic intracranial disease method.

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Table 4:

Methods of TAS and angiographic results in the stenosis group

Patient/Sex/Age (y)	No. of Used Stents	Preprocedure/Postprocedure TIMI^†	Prestenosis/Poststenosis (%)^‡	Technical Success	Procedural Dissections or Clots
17/M/77	3	2/3	95/10	Success	Yes
18/M/65	0	2/3	90/22	Success	No
19/M/78	1	2/3	82/0	Success	Yes
20/M/59	0	1/3	94/30	Success	No
21/M/75	1	2/3	90/12	Success	Yes
22/M/70	0	2/3	80/20	Success	No
23/F/82	0	2/2	90/90	Failure	NE
24/M/64	0	1/3	90/30	Success	No
25/M/60	1	2/3	90/6	Success	Yes
26/M/74	1	2/3	80/10	Success	Yes
27/M/78	0	2/3	84/8	Success	No
28/M/66	1	1/3	95/10	Success	Yes

Note:—TAS, transluminal angioplasty and/or stenting; M, male; F, female; TIMI, Thrombolysis in Myocardial Infarction; NE, no evaluation.
* Data are 10⁴ units.
† Grading with the TIMI definitions, 0 indicates no perfusion; 1, penetration without perfusion; 2, partial perfusion; and 3, complete perfusion.
‡ Preprocedural and postprocedural stenotic ratio was measured with the warfarin-aspirin symptomatic intracranial disease method.

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Table 5:

Complications, subacute occlusion, and neurologic/clinical outcome in the occlusion group

Patient/Sex/Age (y)	Procedure-Related Complications	Major Complications	Subacute Occlusion of the Treated Vessel	NIHSS Score at 7 Days after Procedure	mRS Score at 90 Days after Procedure
1/M/57	None	No	Yes	34	6
2/M/72	Distal embolism	Yes	Yes	28	5
3/M/63	Distal embolism	Yes	Yes	33	5
4/M/75	Hemorrhagic transformation	No	No	10	3
5/F/62	Distal embolism	Yes	No	20	6
6/F/73	None	No	No	42	6
7/M/74	None	No	No	3	1
8/M/77	None	No	No	14	3
9/M/84	None	No	Yes	14	6
10/F/74	None	No	No	7	1
11/M/74	Vessel rupture	Yes	No	42	6
12/M/63	Intracranial hemorrhage	Yes	No	42	6
13/F/76	Subarachnoid hemorrhage	No	No	11	2
14/F/81	None	No	No	17	3
15/F/71	Intracranial hemorrhage	Yes	No	42	6
16/F/60	Distal embolism	No	No	22	5

Note:—NIHSS indicates National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; M, male; F, female.

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Table 6:

Complications, subacute occlusion, and neurologic/clinical outcome in the stenosis group

Patient/Sex/Age (y)	Procedure-Related Complications	Major Complications	Subacute Occlusion of the Treated Vessel	NIHSS Score at 7 Days after Procedure	mRS Score at 90 Days after Procedure
17/M/77	None	No	Yes	31	6
18/M/65	None	No	No	0	0
19/M/78	None	No	No	42	6
20/M/59	None	No	No	0	0
21/M/75	None	No	No	0	0
22/M/70	None	No	No	0	0
23/F/82	Nausea and vomiting	No	No	2	1
24/M/64	None	No	No	0	0
25/M/60	Headache and vomiting	No	No	8	2
26/M/74	None	No	No	0	0
27/M/78	None	No	No	12	6
28/M/66	Headache and vomiting	No	No	4	1

Note:—NIHSS indicates National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; M, male; F, female.

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Table 7:

Comparison of baseline characteristics, procedure, and outcome between the groups

Variable	Data	Subgroup (n = 28)		P
Variable	Data	Occlusion Group (n = 16)	Stenosis Group (n = 12)	P
Age, median (range), y	73.5 (57.0–84.0)	73.5 (57.0–84.0)	72 (59–82)	NS^*
A-NIHSS, median (range), point	8 (1–35)	14.5 (3.0–35.0)	5 (1–33)	<.05^*
P-NIHSS, median (range), point	18 (0–35)	29.5 (12.0–35.0)	2.5 (0.0–33.0)	<.001^*
20 ≤P-NIHSS, n (%)	14 (50)	13 (81)	1 (8)	.0001^‡
OTD time, median (range), h	5.5 (1.0–51.0)	5 (1-48)	8 (2–51)	NS^*
OTP time, median (range), h	41.5 (3.0–168.0)	9.5 (3.0–72.0)	109 (4–168)	<.01^*
Stenting, n (%)	13 (46)	7 (44)	6 (50)	.74^†
LIF, n (%)	4 (14)	4 (25)	0 (0)	.09^‡
Technical success, n (%)	24 (86)	13 (81)	11 (92)	.42^‡
Major complication, n (%)	6 (21)	6 (38)	0 (0)	.02^‡
Subacute occlusion, n (%)	5 (18)	4 (25)	1 (8)	.27^‡
7-NIHSS ≤5 at 7 days, n (%)	8 (29)	1 (6)	7 (58)	.004^‡
mRS ≤2 at 90 days, n (%)	12 (43)	3 (19)	9 (75)	.004^†
Death within 90 days, n (%)	10 (36)	7 (44)	3 (25)	.27^‡

Note:—A-NIHSS indicates National Institutes of Health Stroke Scale score on admission; P-NIHSS, preprocedural National Institutes of Health Stroke Scale score; OTD time, onset-to-door time; OTP time, onset-to-procedure time; LIF, localized intra-arterial fibrinolysis; 7-NIHSS, National Institutes of Health Stroke Scale score at 7 days; mRS, modified Rankin Scale; NS, not significant.
* Data are from Mann-Whitney U test.
† Data are from χ² test for independence.
‡ Data are from Fisher exact test.