I based my review on personal knowledge of the subject supplemented by data derived from multi-centre randomised trials, non-randomised controlled studies with independent outcome ascertainment, and selected observational studies. The information was identified with multiple searches on MEDLINE from 1985 to the present by cross referencing key words of cerebrovascular disease, stroke, intracranial neoplasms, or clinical trials, with intra-arterial thrombolysis, angioplasty, stent, embolisation,
ReviewEndovascular treatment of cerebrovascular diseases and intracranial neoplasms
Introduction
Cerebrovascular diseases are a major global health problem, result in high morbidity and mortality, and are the leading cause of disability.1 Over the past few years, developments in endovascular treatments for cerebrovascular diseases have expanded the horizon of treatment by use of minimally invasive techniques. In endovascular treatment, drugs and devices are introduced through catheters or microcatheters placed into blood vessels through the skin. The initial work of Haschek, Lindenthal, and Moniz2 led to development of cerebral angiography as a diagnostic method. In the early 1960s, Luessenhop and Velasquez3 showed that intracranial vessels could be catheterised with flow-directed balloon tipped catheters, and in 1974, Serbinenko4 reported use of balloon tipped micro-catheters and detachable balloons for treatment of intracranial aneurysms—starting the use of endovascular procedures as a method of treatment.
The basic principle of all endovascular procedures involves percutaneous entry into the femoral, radial, or brachial artery5, 6 by use of a modification of Seldinger's technique.7 Guide catheters or sheaths are introduced through the aorta into the supra-aortic vessel of interest. Microcatheters, balloon catheters, and stent delivery devices are introduced through the guide catheter and guided to the target lesion with flexible microwires. Advanced designs of microcatheters including flow directed and magnetically guided microcatheters8 have allowed highly selective delivery of coils, embolic materials, and drugs into regions of interest.
Section snippets
Acute ischaemic stroke
In 1958, Sussmann and Fitch9 reported successful recanalisation of an acutely occluded internal carotid artery after intra-arterial injection of plasmin. Subsequent attempts at intra-arterial administration of thrombolytics were unsuccessful because the time window for intervention was not clearly understood and doctors had little experience in guiding catheters into the intracranial vessels. With better understanding of the time window, randomised trials10, 11 showed the benefit of using
Carotid stenosis
Randomised trials have shown the benefit of carotid endarterectomy in reducing the risk of stroke in patients with moderate to severe symptomatic (⩾50%)34, 35, 36 or asymptomatic (⩾60%)37 carotid artery stenosis. However, in general practice, perioperative complications are sometimes high enough that potential benefits are obscured when carotid endarterectomy is done on patients with unfavourable clinical and anatomical characteristics.38, 39, 40, 41, 42 Carotid angioplasty with stent placement
Intracranial stenosis
Intracranial stenosis is responsible for 8–10% of all ischaemic strokes.81, 82 The yearly rate of recurrent stroke in patients with intracranial stenosis is about 8–12%83, 84 and for those who do not respond to antithrombotic treatment, the rate of recurrent ischaemic events can be as high as 52%.85 Patients with symptomatic vertebrobas-ilar stenosis have a low stroke-free survival rate of 76% at 12months and 48% at 5years.82 Percutaneous translumi-nal angioplasty with possible stent placement
Intracranial aneurysms
Intracranial aneurysms are an important health problem worldwide, affecting about 2% of the population.90 In 1941, Werner and colleagues91 inserted silver wires into an intracranial aneurysm by use of a transorbital approach to prevent rupture by protecting the susceptible wall of the aneurysm from the stress of pulsatile blood. Subsequently, placement of iron particles, detachable balloons, and pushable platinum coils was attempted.2 In the late 1980s, soft platinum coil soldered to a
Arteriovenous malformations
In 1930, Brooks117 reported closure of carotid-cavernous fistula with surgical introduction of muscle embolus in the carotid artery. Lussenhop and colleagues118 subsequently reported embolisation with silastic spheres and silk sutures introduced into the internal carotid artery to treat cerebral arteriovenous malformation. Technical advances such as flow directed and other specialised microcatheters and new embolic agents have increased the therapeutic potential of embolisation for cerebral
Intracranial tumours
Intra-arterial delivery of chemotherapeutic agents into the vascular bed of intracranial tumours has been suggested to achieve a high concentration in selected regions of the brain.129 A phase III trial130 showed no difference in survival between the 153 patients with newly resected malignant glioma who were randomly allocated to intracarotid injection of carmustine and the 126 who received this compound intravenously. Serious toxic effects in the intra-arterial group, consisting of
Future applications
The safety and efficacy of endovascular procedures for cerebrovascular diseases is expected to improve with new technology. New applications such as intra-arterial delivery of stem cells derived from bone marrow to damaged regions of the brain have shown promise in experimental models.139 These cells can be deposited in the regions of injured brain, survive, and express proteins similar to neurons. The intra-arterial route has also been proposed as a method for delivering plasmid DNA
Search strategy and selection criteria
References (140)
- et al.
A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study
J Am Coll Cardiol
(1997) - et al.
Randomized double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators
Lancet
(1998) - et al.
Preprocedural risk stratification: identifying an appropriate population for carotid stenting
J Vasc Surg
(2001) - et al.
Multicenter evaluation of carotid artery stenting with a filter protection system
J Am Coll Cardiol
(2002) - et al.
Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial
J Vasc Surg
(1998) - et al.
Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital
JAm Coll Cardiol
(2001) Carotid stenting in the CREST lead-in phase: periprocedural stroke, myocardial infarction, and death rates
Stroke
(2003)- et al.
Stroke: the global burden
Health Policy Plan
(1995) - et al.
Treating complex nervous system vascular disorders through a “needle stick”: origins, evolution, and future of neuroendovascular therapy
Neurosurgery
(2001) - et al.
Observations on the tolerance of the intracranial arteries to catheterization
J Neurosurg
(1964)
Balloon catheterization and occlusion of major cerebral vessels
J Neurosurg
Transradial approach for vertebral artery stenting: technical case report
Neurosurgery
Catheter replacement of the needle in percutaneous angiography: a new technique
Acta Radiol
Magnetically controlled endovascular navigation: in vivo experience
J Neurosurg
Thrombolysis with fibrinolysis in cerebral arterial occlusion
JAMA
Tissue plasminogen activator for acute ischemic stroke: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
N Engl J Med
Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study
JAMA
Acute interventions for ischemic stroke: Present status and future directions
J Endovasc Ther
Intra-arterial third-generation recombinant tissue plasminogen activator (reteplase) for acute ischemic stroke
Neurosurgery
Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study
Neurosurgery
Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy
Am J Neuroradiol
Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism
JAMA
Safety of intra-arterial thrombolysis in the postoperative period
Stroke
Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke
AnnNeurol
Differential response to intravenous versus intra-arterial thrombolysis in acute ischemic stroke on the basis of hyperdense middle cerebral artery sign
Stroke
New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke
Neurosurgery
Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke
Stroke
Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke
Stroke
PROACT: aPhase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke—PROACT Investigators: Prolyse in Acute Cerebral Thromboembolism
Stroke
Intraarterial recombinant tissue plasminogen activator for ischemic stroke: An accelerating dosing regimen
Neurosurgery
Local intraarterial fibrinolytic therapy in patients with stroke: urokinase versus recombinant tissue plasminogen activator (r-TPA)
Neuroradiology
Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial
Stroke
The Interventional Management of Stroke (IMS) Study: safety results
Stroke
Mechanical thrombolysis for acute ischemic stroke
Neurointerventionist
North American clinical experience with the EKOS MicroLysUS infusion catheter for treatment of embolic stroke
Am J Neuroradiol
EPAR therapy system for treatment of acute stroke: safety study results
Stroke
Acute basilar artery occlusion treated with combined intravenous Abciximab and intra-arterial tissue plasminogen activator: report of 3 cases
Stroke
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis
N Engl J Med
Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis
N Engl J Med
Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST)
Lancet
Endarterectomy for asymptomatic carotid artery stenosis
JAMA
Comparison of carotid endarterectomy outcomes from randomized controlled trials and Medicare administrative databases
Arch Neurol
Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics
JAMA
Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms
Stroke
Multicenter review of preoperative risk factors for endarterectomy for asymptomatic carotid artery stenosis
Stroke
Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review
BMJ
Management of carotid artery stenosis: comparing endarterectomy and stenting
Curr Cardiol Rep
Catheter dilatation of proximal carotid stenosis during distal bifurcation endarterectomy
Am J Neuroradiol
Percutaneous angioplasty of atherosclerotic and post surgical stenosis of carotid arteries
Am J Neuroradiol
Cited by (115)
Balloon-mounting stent versus balloon angioplasty for intracranial arterial stenosis: A systematic review and meta-analysis
2024, Journal of Stroke and Cerebrovascular DiseasesPlasmin (Human) Administration in Acute Middle Cerebral Artery Ischemic Stroke: Phase 1/2a, Open-Label, Dose-Escalation, Safety Study
2017, Journal of Stroke and Cerebrovascular DiseasesEndovascular therapies for malignant gliomas: Challenges and the future
2016, Journal of Clinical NeuroscienceSuccessful Preoperative Endovascular Embolization of an Extreme Hypervascular Glioblastoma Mimicking an Arteriovenous Malformation
2016, World NeurosurgeryCitation Excerpt :Preoperative embolization to facilitate surgery is generally accepted as helpful for extraaxial tumors, such as meningiomas.3 This procedure has been established as an effective adjunct in decreasing intraoperative blood loss,3,4 resulting in softening of the tumor. However, preoperative endovascular embolization of hypervascular glioblastomas has not been established.