Abstract

Aim: was to evaluate the effectiveness of carotid arterial revascularization by stenting of internal carotid arteries (ICA) in patients with a previous ischemic stroke.

Materials and methods: in FSBI «Treatment and rehabilitation center» of the Ministry of Health of Russia,104 patients on treatment and rehabilitation after previous ischemic stroke, underwent stenting of symptomatic atherosclerotic stenosis of the ICA. The average time since stroke was 67 days (from 28 to 273 days). ICA stenting was performed according to generally accepted standards with the mandatory use of intravascular protective devices against cerebral embolism. In most patients we used a filter protection system (77 observations), and for stenosis of more than 95% and in the presence of an unstable atherosclerotic plaque, a proximal defense system was used (27 patients). In some cases, if the situation required it, a combination of protective devices was used (5 observations). A few days before upcoming operation, all patients were evaluated for microcirculation and perfusion in brain tissue using single photon emission computed tomography (SPECT), followed by analysis of results and comparison with SPECT data in the postoperative period.

Results: when analyzing 30 days after stenting, there were no fatal outcomes. In one case (0.96%) after stenting of the subtotal stenosis of the ICA, a hemorrhagic stroke on the ipsilateral side developed on the fifth day. In another case, intraoperative embolism of the ophthalmic artery occurred on the side of the operation with partial loss of vision field.

In the long-term period (4 years and 7 months), the number of undesirable events was 2%. In one case (0.96%), the patient died of ischemic stroke on the ipsilateral side after 3 years and 2 months after stenting. In another case, patient after 1 year and 2 months had an ischemic stroke on the side of the operation. Thus, the total number of complications associated with ICA stenting (30-day period + long-term period) was 3.8%.

When evaluating results of stenting by the SPECT method, the state of cerebral perfusion was assessed using perfusion maps in two modes and by axial perfusion sections.

In all observations after stenting, improvement of cerebral perfusion was noticed, regardless of the side and severity of ICA stenosis and the presence of focal postischemic changes. Visually, perfusion sections show a general increase in cerebral blood perfusion (CBP), a decrease in one-sided focal deficiency of CBP . Same results were obtained for relative cortex perfusion (relCP) in four regions and in vascular basins.

Comparing results, obtained by the number of undesirable events (strokes, restenosis and death) with the four-year data of the analysis of the international CREST study, the complication rate in our group is significantly lower (3.8% versus 8.6% in the CREST stenting group and 8.4% in carotid endarterectomy group CREST).

Conclusion: carotid stenting is an effective method of treatment of atherosclerotic lesions of main cerebral arteries in patients with previous stroke. The effectiveness of this type of treatment is confirmed by a positive clinical result and with the help of modern diagnostic methods, in particular SPECT.

References

1.     Damulin IV, Parfenov VA, Skoromets AA, Yah NN. Circulatory disorders in the brain and spinal cord. In the book: «Diseases of the nervous system. A guide for doctors». Yakhno N.N., Shtulman D.R. (ed.). 2003; 231302 [In Russ].

2.     Thom T, Haase N, Rosamond W et al. Heart disease and stroke statistics - 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85-151.

3.     Kleindorfer D, Panagos P, Pancioli A et al. Incidence and short term prognosis of transient ischemic attack in a population-based study. Stroke. 2005;36: 720-723.

4.     Gusev EI, Skvortsova VI, Stakhovskaya LV. The problem of stroke in the Russian Federation: a time of active joint action. Zhurn. nevrol. and a psychiatrist. 2007; 8: 4-10 [In Russ].

5.     Gusev EI, Skvortsova VI, Stakhovskaya LV. Epidemiology of stroke in the Russian Federation. appendix of the Journal. nevrol. and a psychiatrist. them. SS Korsakova. 2003; 8: 4-9 [In Russ].

6.     Pinchuk EA. «Epidemiology and secondary prevention of ischemic stroke in a large industrial and cultural center» Diss. Cand. med. sciences. Ekaterinburg, 2004;136-137 [In Russ].

7.     Kadykov AS. Prevention of repeated ischemic stroke. AS Kadykov, NV Shakhparonova. Consilium medicum. 2006; 2: 96-99 [In Russ].

8.     Pokrovsky AV, KiyashkoVA. Ischemic stroke can be prevented. Rus. med. Journal. 2003; 11 (12): 691-695 [In Russ].

9.     Parfenov VA, Gurak SV. Repeated ischemic stroke and its prevention in patients with arterial hypertension. Zhurn. nevrol. and psychiatrist. them. SS Korsakova. Stroke. 2005; 14: 3-7 [In Russ].

10.   Sacco RL, Adams R, Albers G et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Stroke. 2006; 37: 577 - 617.

11.   Touze E, Varenne O, Chatellier G et al. Risk of myocardial infarction and vascular death after transient ischemic attack and ischemic stroke: a systematic review and meta-analysis. Stroke. 2005; 36:2748-2755.

12.   Kjellstrom T, Norrving B, Shatchkute A. Helsingborg Declaration 2006 on European Stroke Strategies. Helsingborg Declaration 2006 On European Stroke Strategies; pp. 9-12. Cerebrovasc Dis. 2007; 23(2-3): 231-41.

13.   European Carotid Surgery Triallists Collaborative Group: NRC European Carotid Surgery Trial; Interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet. 1991; 337:1235-1243.

14.   North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effects of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med. 1991; 325:445-453.

15.   Asymptomatic Carotid Atherosclerosis Study. Clinical advisory: Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. Stroke. 1994; 25:2523-2524.

16.   Brott TG, Hobson RW 2nd, Howard G, Roubin FS, et al. "CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23.

17.   Brown MM, Mas JL, Ringleb PA, Hacke W. Carotid artery stenting versus surgery: adequate comparisons? Lancet Neurol. 2010 , 9:341-342.

18.   Volzhenin VE, Dolinina EG, Dontsov AE et al. The state of cerebral blood flow according to SPECT, MRI and MPA. Thes. doc. 2nd Congress of the Russian Society of Nuclear Medicine. Modern problems of nuclear medicine and pharmaceuticals. Obninsk, 2000; 174-175 [In Russ].