Osama O. Zaidat

Intracranial arterial stenosis is a common stroke etiology worldwide.^1-6 The recurrent stroke risk with severe symptomatic intracranial stenosis (≥70%) may be as high as 23% at 1 year, despite medical therapy.^7,8 Endovascular options are limited to balloon angioplasty only, self-expanding stent, balloon-expanding stent, or a combination of these therapies. The SAMMPRIS (Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis) trial showed that aggressive medical therapy alone was superior to percutaneous transluminal balloon angioplasty followed by stenting using the Wingspan self-expanding stent (Stryker) with an absolute difference of 8.9% at 30 days and 9.0% at 3 years in the primary outcome.^9-11 The 30-day event rates with medical therapy were nearly one-half of the reported event rates in the WASID (Warfarin-Aspirin Symptomatic Intracranial Disease) trial and the balloon angioplasty with stenting results were nearly double the rates that were reported in prior stenting registries.^7,8,12-14

Background and Purpose—: The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry. Methods—: The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age. Results—: Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years ( P =0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively ( P =0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality. Conclusion—: Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.

BACKGROUND: Previous studies have demonstrated that cerebral dural sinus stenosis (DSS) may be a potential patho‐physiological cause of idiopathic intracranial hypertension (IIH). Endovascular therapy for DSS is emerging as a potential alternative to treat IIH. Here, we present the results of our case series.METHOD: We prospectively collected angiographic and manometric data on patients that underwent angioplasty/stenting for IIH. All patients had failed maximal medical therapy (MMT) and had confirmed sinus stenosis. Demographic, clinical and radiological presentation, and outcomes were collected retrospectively.RESULTS: A total of 18 patients underwent 25 procedures. Demographics revealed a mean age of 30 (range 15‐59), 83% (15/18) were female, 72% (13/18) were white, and mean body mass index of 36 (range 23‐59.2). All patients presented with classic IIH. Symptom improvement or resolution was reported in 94% (17/18) of patients. All patients had resolution and/or stabilization/improvement of their papilledema. Headaches related to increased pressure improved in 56% (10/18). Re‐stenosis and retreatment occurred in 33% (6/18). No procedural related complications were reported.CONCLUSION: Dural sinus angioplasty and stenting is relatively safe, feasible, and clinically efficacious for patients with symptomatic sinus stenosis who have failed standard therapy. The long‐term durability of patency and clinical improvement remains unknown.

BACKGROUND The effect of oversized intracranial stent implantation, and potential excessive neointimal hyperplasia from the chronic outward radial force, has not been reported. We sought to compare the angiographic narrowing associated with implantation of oversized stents. METHODS We reviewed an aneurysm database and identified patients treated with stent-assisted embolization involving a vessel size transition. Demographics and lesion characteristics were extracted. The relationship between lumen diameter and stent oversizing was compared. RESULTS Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean follow-up time was 8 months (SD 6). The average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm. Mean change in lumen size from pre-stent implantation was not significantly different for any of the four sites. There was a significant difference in change of lumen size at the stent tines when compared with the respective mid-stent segment for both the proximal (P = 0.02) and distal (P = 0.0004) landing zones. CONCLUSIONS A small significant lumen loss occurs at stent tines when compared to midstent struts. However, there is no overall significant stenosis from highly oversized stents. Persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia.