ARTICLE IN PRESS
CLINEU-3686; No. of Pages 1
Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
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Letter to the Editor Intracranial stenting for large vessel recanalization in acute ischemic stroke Keywords: Acute ischemic stroke Endovascular procedures Stents
Dear Sir, I have read, with interest, a recently published article in Clinical Neurology and Neurosurgery by Sung et al. titled ‘Emergent intracranial stenting for acute M2 occlusion of middle cerebral artery’ . The authors report a case series of 10 patients with acute middle cerebral artery M2 segment occlusions who were treated emergently with the Wingspan intracranial stent system (Boston Scientiﬁc, Natick, MA, USA). A Thrombolysis in Cerebral Infarction grade of 2b or higher was achieved in 90% of patients. The mean neurological improvement at seven days, as measured by the National Institute of Health Stroke Scale, was 9 points. At discharge, 60% of patients had a modiﬁed Rankin Scale score of 2 or less. While the data for stenting of chronic intracranial atherosclerotic disease (ICAD) lesions is robust, the safety and efﬁcacy of emergent stenting for acute large vessel occlusion is not well delineated . The timing of the present article is opportune given the signiﬁcant controversy currently surrounding the role of mechanical thrombectomy for acute ischemic stroke [3–5]. Two particularly salient issues are raised by this study, speciﬁcally (1) patient selection and (2) stent design. Regarding patient selection, the patients in this study failed or were ineligible for intravenous thrombolysis but were not treated with mechanical thrombectomy. The authors discuss the relatively poor recanalization rates of the Merci Retriever (Concentric Medical, Mountain View, CA, USA). However, the Merci Retriever has largely been supplanted by stentrievers in light of two recent randomized controlled trials which reported superior angiographic and clinical outcomes with the Solitaire (ev3, Irvine, CA, USA) and Trevo devices (Concentric Medical) compared to the Merci device [6,7]. Therefore, I would be interested to know the rationale of the treating physicians in selecting acute ischemic stroke patients for mechanical thrombectomy versus intracranial stenting. Regarding stent design, the authors endorse their use of the Wingspan self-expanding stent (SES) over balloon-expandable
stents (BES). However, the rate of in-stent restenosis (ISR) associated with BESs has been shown to be lower compared to SESs . As a result, there has been a shift among neurointerventionalists toward increasing utilization of BESs, although the practice of intracranial stenting for ischemic cerebrovascular disease is predominantly reserved for patients with symptomatic, severe ICAD . For patients with acute large vessel occlusions, further followup is necessary to determine the long-term implications of stent design on ISR and recurrent ischemic events. References  Sung SM, Lee TH, Lee SW, Cho HJ, Park KH, Jung DS. Emergent intracranial stenting for acute M2 occlusion of middle cerebral artery. Clin Neurol Neurosurg 2014;119:110–5.  Ding D, Liu KC. Applications of stenting for intracranial atherosclerosis. Neurosurg Focus 2011;30(6):E15.  Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–23.  Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368(10):904–13.  Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368(10):893–903.  Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012;380(9849):1231–40.  Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire ﬂow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380(9849):1241–9.  Jiang WJ, Cheng-Ching E, Abou-Chebl A, Zaidat OO, Jovin TG, Kalia J, et al. Multicenter analysis of stenting in symptomatic intracranial atherosclerosis. Neurosurgery 2012;70(1):25–30, discussion 31.  Ding D, Starke RM, Crowley RW, Liu KC. Role of stenting for intracranial atherosclerosis in the post-SAMMPRIS Era. Biomed Res Int 2013;2013:304320.
Dale Ding ∗ University of Virginia, Department of Neurosurgery, Charlottesville, USA ∗ Correspondence to: University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, USA. Tel.: +1 434 924 2203; fax: +1 434 982 5753. E-mail address: [email protected]
1 April 2014 Available online xxx
http://dx.doi.org/10.1016/j.clineuro.2014.04.009 0303-8467/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Ding D. Intracranial stenting for large vessel recanalization in acute ischemic stroke. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2014.04.009