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Marc I Chimowitz - One of the best experts on this subject based on the ideXlab platform.
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does the stenting versus aggressive medical therapy trial support stenting for subgroups with Intracranial Stenosis
Stroke, 2015Co-Authors: Helmi L. Lutsep, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Bethany F Lane, Tanya N. Turan, Jean Montgomery, Scott L Janis, Marc I ChimowitzAbstract:Background and Purpose— Although the Stenting Versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial showed that medical therapy alone was superior to stenting plus medical therapy for preventing recurrent strokes in patients with symptomatic Intracranial Stenosis, we determined whether SAMMPRIS supported the use of stenting in any subpopulations of patients with symptomatic Intracranial arterial Stenosis. Methods— The primary outcome, 30-day stroke and death and later strokes in the territory of the qualifying artery, was compared in those with and without baseline factors in the 2 treatment arms, percutaneous transluminal angioplasty and stenting (PTAS) plus aggressive medical therapy versus aggressive medical therapy alone. Baseline factors included sex, age, race, diabetes mellitus, hypertension, lipid disorder, smoking status, type of qualifying event, qualifying event hypoperfusion symptoms, use of antithrombotic or proton pump inhibitor at baseline, days to enrollment, old infarcts in the same territory, percent Stenosis, other artery Stenosis, and location of the symptomatic artery. Results— A total of 451 patients were enrolled, 227 randomized to aggressive medical therapy and 224 to PTAS. Of all variables evaluated, the observed 2-year event rates were higher with PTAS than with aggressive medical therapy in the vast majority and the interaction with treatment was not statistically significant for any of the factors. Conclusions— The SAMMPRIS results do not provide evidence to support the use of PTAS using the Wingspan stent system compared with medical treatment in any examined subpopulation of patients with symptomatic Intracranial Stenosis, including those with qualifying event hypoperfusion symptoms. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00576693.
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noninvasive fractional flow on mra predicts stroke risk of Intracranial Stenosis
Journal of Neuroimaging, 2015Co-Authors: David S. Liebeskind, Michael J. Lynn, Marc I Chimowitz, Andrzej S. Kosinski, Fabien Scalzo, Albert K Fong, Pari Fariborz, Edward FeldmannAbstract:BACKGROUND AND PURPOSE Fractional flow may identify hemodynamic effects and ischemic risk beyond percent Stenosis of an artery. We hypothesized that diminished TOF-MRA signal intensity distal to an Intracranial Stenosis predicts stroke risk. METHODS TOF-MRA was acquired prospectively in the SONIA-WASID trials. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest, blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures to identify predictors for risk of stroke in the territory. RESULTS 189 patients with 50-99% symptomatic Intracranial Stenosis in SONIA-WASID had TOF-MRA available. In univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < .9 was 5.2 (1.8, 15.3; P < .001) as compared to SIR ≥ .9. Multivariate analysis correcting for baseline systolic blood pressure, LDL, centrally measured percent Stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < .9 was 10.9 (2.0, 58.9; P < .001). In those with <70% Stenosis, a SIR < .9 maintained a significant association with recurrent stroke in the territory (P = .006), with a 2-year event rate of 17.3%. CONCLUSIONS Fractional flow assessed by TOF-MRA SIR may be a useful noninvasive tool to identify high-risk Intracranial lesions. CLINICAL TRIAL REGISTRATION-URL This trial was not registered because enrollment began prior to July 1, 2005.
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Treatment Trends In Management Of Intracranial Stenosis In The Pre- And Post-Sammpris Era (I8-1.008)
Neurology, 2014Co-Authors: Swaroop Pawar, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Tanya N. Turan, Rahim H. Wooley, Barney J. Stern, Marc I ChimowitzAbstract:BACKGROUND: Treatment of Intracranial Stenosis has evolved over the course of the last 2 decades. This survey sought to define the impact of, ‘Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS)’ an NIH-sponsored clinical trial on treatment trends of physicians in managing Intracranial Stenosis. METHODS: Surveys of treatment choices were sent 1 year post-publication of the SAMMPRIS Trial results. (2012). A similar survey designed in the Post- Warfarin Vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial Era, another NIH-sponsored clinical trial was used to compare treatment trends (pre-SAMMPRIS survey). Both the surveys were sent to neurologists as well as neurointerventionists. The post-SAMMPRIS survey addressed questions regarding the maximum benefit physicians would require to recommend a new endovascular treatment to their patients. Data was analyzed using the chi-square tests. RESULTS: Post-SAMMPRIS, the number of respondents recommending antiplatelet treatment for Intracranial Stenosis increased. Compared to the post-WASID/pre-SAMMPRIS respondents, more post-SAMMPRIS respondents preferred antiplatelet agents for Stenosis in the anterior circulation (85% vs. 94%, p=0.0017) and posterior circulation (74% vs. 83%, p=0.0145). The antiplatelet agent most post-SAMMPRIS was the combination of aspirin and clopidogrel. The percentage of neurologists who recommended percutaneous transluminal angioplasty and stenting (PTAS) in > 25% of ICAS patients decreased from pre-SAMMPRIS (12%) to post-SAMMPRIS (6%), while for neurointerventionists, it decreased from (49%) to (17%). DISCUSSION: SAMMPRIS had a major impact on treatment trends of physicians managing patients with Intracranial Stenosis. In the Post-SAMMPRIS survey, 91% of respondents participating in SAMMPRIS and 82% of overall respondents indicated that the SAMMPRIS results changed the way they managed patients with ICAS.As aggressive medical management coupled with optimal risk factor reduction shows promise in reducing rates of recurrent stroke, a novel endovascular therapy will have to seek newer heights of increasing RRR to gain acceptance by practitioners. Disclosure: Dr. Pawar has nothing to disclose. Dr. Turan has received personal compensation for activities with Gore Laboratories Inc., and Boehringer Ingelheim Pharmaceuticals Inc. Dr. Turan has received research support from Stryker Co., the National Institutes of Health, and AstraZeneca. Dr. Cotsonis has nothing to disclose. Dr. Lynn has nothing to disclose. Dr. Wooley has nothing to disclose. Dr. Stern has received personal compensation for activities with Lippincott Williams & Wilkins. Dr. Stern has received personal compensation in an editorial capacity for The Neurologist. Dr. Derdeyn has received personal compensation for activities with W.L. Gore and Associates, Boston Scientific Corporation, and Target Therapeutics. Dr. Fiorella has received personal compensation for activities with Covidien/ev3, Codman/Micrus/JNJ, NFocus, Vascular Simulations, CSVL, Microvention/Terumo, and Siemens Medical Imaging. Dr. FIorella has received royalty, or license fee, or contractual rights payments from Codman/Micrus/JNJ. Dr. Fiorella has received research support from Microvention and Siemens Medical Imaging. Dr. Chimowitz has received personal compensation for activities with Axio Research, Merck & Co. Inc., and Gore. Dr. Chimowitz has received research support from the National Institute of Neurological Disorders and Stroke, Stryker, and Boston Scientific Corporation.
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Association Between Lipoprotein (a) Levels and Vascular Events in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. (P1.147)
Neurology, 2014Co-Authors: Swaroop Pawar, Tanya N. Turan, Marc I ChimowitzAbstract:Background: Lipoprotein (a) (Lp(a)) is an atherothrombogenic lipid particle that has been associated with severity and extent of Intracranial atherosclerosis. We sought to determine the prevalence of high Lp(a) as well as the association of high Lp(a) with other baseline vascular risk factors in patients with symptomatic Intracranial Stenosis in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Methods: The main SAMMPRIS entrance criteria were a TIA or non-disabling stroke ≤ 30 days prior to enrollment due to 70-99% Intracranial atherosclerosis. Data on patients with baseline Lp(a) values measured at a Central Core Lab were used for these analyses (n=446). High Lp(a) was defined as > 35 mg/dL in Whites and > 65 mg/dL in Blacks, based on prior studies. Baseline characteristics and vascular risk factors were compared in patients with high Lp(a) to those with normal Lp(a) in univariate and multivariate analyses. Results: Baseline Lp(a) was high in 30/55(55%) of Black males, 29/49(59%) of Black females, 86/202(43%) of White males, and 39/116(34%) of White females. Baseline features associated with high Lp(a) in the univariate analyses are shown in Table 1. Multivariate analysis showed that high Lp(a) was independently associated with higher HDL (p=0.0182) and any lipid lowering medication use prior to enrollment (p= 0.0138), and there was a trend toward an association with higher BMI (p=0.0521). Conclusion: SAMMPRIS patients had a high prevalence of high Lp(a), consistent with prior studies of patients with Intracranial Stenosis, suggesting Lp(a) may have a pathogenic role in Intracranial Stenosis. However, high Lp(a) was associated with other vascular risk factors and may therefore be a component of an overall elevated risk factor profile. Further analyses of the SAMMPRIS results (after follow-up is completed) will determine if there is an association between high Lp(a) and recurrent stroke risk. Disclosure: Dr. Pawar has nothing to disclose. Dr. Turan has received personal compensation for activities with Gore Laboratories Inc., and Boehringer Ingelheim Pharmaceuticals Inc. Dr. Turan has received research support from Stryker Co., the National Institutes of Health, and AstraZeneca. Dr. Chimowitz has received personal compensation for activities with Axio Research, Merck & Co. Inc., and Gore. Dr. Chimowitz has received research support from the National Institute of Neurological Disorders and Stroke, Stryker, and Boston Scientific Corporation.
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Noninvasive Fractional Flow on MRA Predicts Stroke Risk of Intracranial Stenosis
Journal of Neuroimaging, 2014Co-Authors: David S. Liebeskind, Michael J. Lynn, Marc I Chimowitz, Andrzej S. Kosinski, Fabien Scalzo, Albert K Fong, Pari Fariborz, Edward FeldmannAbstract:BACKGROUND AND PURPOSE Fractional flow may identify hemodynamic effects and ischemic risk beyond percent Stenosis of an artery. We hypothesized that diminished TOF-MRA signal intensity distal to an Intracranial Stenosis predicts stroke risk. METHODS TOF-MRA was acquired prospectively in the SONIA-WASID trials. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest, blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures to identify predictors for risk of stroke in the territory. RESULTS 189 patients with 50-99% symptomatic Intracranial Stenosis in SONIA-WASID had TOF-MRA available. In univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < .9 was 5.2 (1.8, 15.3; P < .001) as compared to SIR ≥ .9. Multivariate analysis correcting for baseline systolic blood pressure, LDL, centrally measured percent Stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < .9 was 10.9 (2.0, 58.9; P < .001). In those with
Michael J. Lynn - One of the best experts on this subject based on the ideXlab platform.
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does the stenting versus aggressive medical therapy trial support stenting for subgroups with Intracranial Stenosis
Stroke, 2015Co-Authors: Helmi L. Lutsep, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Bethany F Lane, Tanya N. Turan, Jean Montgomery, Scott L Janis, Marc I ChimowitzAbstract:Background and Purpose— Although the Stenting Versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial showed that medical therapy alone was superior to stenting plus medical therapy for preventing recurrent strokes in patients with symptomatic Intracranial Stenosis, we determined whether SAMMPRIS supported the use of stenting in any subpopulations of patients with symptomatic Intracranial arterial Stenosis. Methods— The primary outcome, 30-day stroke and death and later strokes in the territory of the qualifying artery, was compared in those with and without baseline factors in the 2 treatment arms, percutaneous transluminal angioplasty and stenting (PTAS) plus aggressive medical therapy versus aggressive medical therapy alone. Baseline factors included sex, age, race, diabetes mellitus, hypertension, lipid disorder, smoking status, type of qualifying event, qualifying event hypoperfusion symptoms, use of antithrombotic or proton pump inhibitor at baseline, days to enrollment, old infarcts in the same territory, percent Stenosis, other artery Stenosis, and location of the symptomatic artery. Results— A total of 451 patients were enrolled, 227 randomized to aggressive medical therapy and 224 to PTAS. Of all variables evaluated, the observed 2-year event rates were higher with PTAS than with aggressive medical therapy in the vast majority and the interaction with treatment was not statistically significant for any of the factors. Conclusions— The SAMMPRIS results do not provide evidence to support the use of PTAS using the Wingspan stent system compared with medical treatment in any examined subpopulation of patients with symptomatic Intracranial Stenosis, including those with qualifying event hypoperfusion symptoms. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00576693.
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noninvasive fractional flow on mra predicts stroke risk of Intracranial Stenosis
Journal of Neuroimaging, 2015Co-Authors: David S. Liebeskind, Michael J. Lynn, Marc I Chimowitz, Andrzej S. Kosinski, Fabien Scalzo, Albert K Fong, Pari Fariborz, Edward FeldmannAbstract:BACKGROUND AND PURPOSE Fractional flow may identify hemodynamic effects and ischemic risk beyond percent Stenosis of an artery. We hypothesized that diminished TOF-MRA signal intensity distal to an Intracranial Stenosis predicts stroke risk. METHODS TOF-MRA was acquired prospectively in the SONIA-WASID trials. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest, blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures to identify predictors for risk of stroke in the territory. RESULTS 189 patients with 50-99% symptomatic Intracranial Stenosis in SONIA-WASID had TOF-MRA available. In univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < .9 was 5.2 (1.8, 15.3; P < .001) as compared to SIR ≥ .9. Multivariate analysis correcting for baseline systolic blood pressure, LDL, centrally measured percent Stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < .9 was 10.9 (2.0, 58.9; P < .001). In those with <70% Stenosis, a SIR < .9 maintained a significant association with recurrent stroke in the territory (P = .006), with a 2-year event rate of 17.3%. CONCLUSIONS Fractional flow assessed by TOF-MRA SIR may be a useful noninvasive tool to identify high-risk Intracranial lesions. CLINICAL TRIAL REGISTRATION-URL This trial was not registered because enrollment began prior to July 1, 2005.
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Treatment Trends In Management Of Intracranial Stenosis In The Pre- And Post-Sammpris Era (I8-1.008)
Neurology, 2014Co-Authors: Swaroop Pawar, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Tanya N. Turan, Rahim H. Wooley, Barney J. Stern, Marc I ChimowitzAbstract:BACKGROUND: Treatment of Intracranial Stenosis has evolved over the course of the last 2 decades. This survey sought to define the impact of, ‘Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS)’ an NIH-sponsored clinical trial on treatment trends of physicians in managing Intracranial Stenosis. METHODS: Surveys of treatment choices were sent 1 year post-publication of the SAMMPRIS Trial results. (2012). A similar survey designed in the Post- Warfarin Vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial Era, another NIH-sponsored clinical trial was used to compare treatment trends (pre-SAMMPRIS survey). Both the surveys were sent to neurologists as well as neurointerventionists. The post-SAMMPRIS survey addressed questions regarding the maximum benefit physicians would require to recommend a new endovascular treatment to their patients. Data was analyzed using the chi-square tests. RESULTS: Post-SAMMPRIS, the number of respondents recommending antiplatelet treatment for Intracranial Stenosis increased. Compared to the post-WASID/pre-SAMMPRIS respondents, more post-SAMMPRIS respondents preferred antiplatelet agents for Stenosis in the anterior circulation (85% vs. 94%, p=0.0017) and posterior circulation (74% vs. 83%, p=0.0145). The antiplatelet agent most post-SAMMPRIS was the combination of aspirin and clopidogrel. The percentage of neurologists who recommended percutaneous transluminal angioplasty and stenting (PTAS) in > 25% of ICAS patients decreased from pre-SAMMPRIS (12%) to post-SAMMPRIS (6%), while for neurointerventionists, it decreased from (49%) to (17%). DISCUSSION: SAMMPRIS had a major impact on treatment trends of physicians managing patients with Intracranial Stenosis. In the Post-SAMMPRIS survey, 91% of respondents participating in SAMMPRIS and 82% of overall respondents indicated that the SAMMPRIS results changed the way they managed patients with ICAS.As aggressive medical management coupled with optimal risk factor reduction shows promise in reducing rates of recurrent stroke, a novel endovascular therapy will have to seek newer heights of increasing RRR to gain acceptance by practitioners. Disclosure: Dr. Pawar has nothing to disclose. Dr. Turan has received personal compensation for activities with Gore Laboratories Inc., and Boehringer Ingelheim Pharmaceuticals Inc. Dr. Turan has received research support from Stryker Co., the National Institutes of Health, and AstraZeneca. Dr. Cotsonis has nothing to disclose. Dr. Lynn has nothing to disclose. Dr. Wooley has nothing to disclose. Dr. Stern has received personal compensation for activities with Lippincott Williams & Wilkins. Dr. Stern has received personal compensation in an editorial capacity for The Neurologist. Dr. Derdeyn has received personal compensation for activities with W.L. Gore and Associates, Boston Scientific Corporation, and Target Therapeutics. Dr. Fiorella has received personal compensation for activities with Covidien/ev3, Codman/Micrus/JNJ, NFocus, Vascular Simulations, CSVL, Microvention/Terumo, and Siemens Medical Imaging. Dr. FIorella has received royalty, or license fee, or contractual rights payments from Codman/Micrus/JNJ. Dr. Fiorella has received research support from Microvention and Siemens Medical Imaging. Dr. Chimowitz has received personal compensation for activities with Axio Research, Merck & Co. Inc., and Gore. Dr. Chimowitz has received research support from the National Institute of Neurological Disorders and Stroke, Stryker, and Boston Scientific Corporation.
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Noninvasive Fractional Flow on MRA Predicts Stroke Risk of Intracranial Stenosis
Journal of Neuroimaging, 2014Co-Authors: David S. Liebeskind, Michael J. Lynn, Marc I Chimowitz, Andrzej S. Kosinski, Fabien Scalzo, Albert K Fong, Pari Fariborz, Edward FeldmannAbstract:BACKGROUND AND PURPOSE Fractional flow may identify hemodynamic effects and ischemic risk beyond percent Stenosis of an artery. We hypothesized that diminished TOF-MRA signal intensity distal to an Intracranial Stenosis predicts stroke risk. METHODS TOF-MRA was acquired prospectively in the SONIA-WASID trials. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest, blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures to identify predictors for risk of stroke in the territory. RESULTS 189 patients with 50-99% symptomatic Intracranial Stenosis in SONIA-WASID had TOF-MRA available. In univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < .9 was 5.2 (1.8, 15.3; P < .001) as compared to SIR ≥ .9. Multivariate analysis correcting for baseline systolic blood pressure, LDL, centrally measured percent Stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < .9 was 10.9 (2.0, 58.9; P < .001). In those with
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Abstract T MP33: Biomarkers of Ischemic Outcomes in Symptomatic Intracranial Stenosis (BIOSIS) - Preliminary Results
Stroke, 2014Co-Authors: Michael Frankel, Michael J. Lynn, Arshed A. Quyyumi, Yize Zhao, Qi Long, Ngoc-anh Le, Edmund K. Waller, Juan F. Arenillas, Bethany F Lane, Marc I ChimowitzAbstract:Background and Purpose: Intracranial atherosclerosis is a common cause of stroke. Although inflammatory biomarkers correlate with coronary artery disease, it is not known whether biomarkers of inflammation and endothelial repair are predictive of stroke in patients with Intracranial atherosclerosis.The purpose of this study is to determine whether serum biomarkers of inflammation and the number of circulating progenitor cells (PCs) in patients with symptomatic Intracranial Stenosis are independent predictors of ischemic stroke. Methods: Blood samples from patients in SAMMPRIS, a clinical trial comparing stenting plus medical treatment with medical treatment alone in patients with symptomatic Intracranial Stenosis, were obtained at study entry. Levels of inflammatory biomarkers (PAI-1, E-selectin, hsCRP, LpPLA2) and PCs were analyzed in relation to outcome events. Pre-specified outcomes of interest included stroke in the territory of the symptomatic stenotic artery and any ischemic stroke. The hazard ratio (HR) for each biomarker was determined in relation to outcome events using continuous and dichotomized values (median as cutpoint). Results: There were 451 patients with baseline blood samples. Median follow-up was 32.4 months. In patients randomized to medical treatment only, dichotomized biomarker values revealed an association between elevated levels of PAI-1 [1.85 (0.95-3.62), p=0.07)], hsCRP [1.82 (0.96-3.44), p=0.06] and any ischemic stroke. PAI-1 was also associated with any ischemic stroke when analyzed as a continuous variable [1.2 (1.02-1.40), p=0.03]. None of the other inflammatory markers were associated with outcomes. Low levels of PCs enumerated as CD45med, CD34+/CD133+ dual positive cells also revealed a trend toward association with ischemic stroke in the territory of the symptomatic stenotic artery for the treatment groups combined [1.56 (0.93-2.63), p=0.09]. Conclusion: Elevated levels of PAI-1 and hsCRP are associated with risk of any ischemic stroke in patients with symptomatic Intracranial Stenosis treated with aggressive medical therapy. Low PC levels also appear to be associated with increased risk of recurrent stroke. As the SAMMPRIS trial reaches completion, multivariable analyses will be completed.
Adnan I. Qureshi - One of the best experts on this subject based on the ideXlab platform.
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Abstract 3: Stent Placement versus Best Medical Therapy for Symptomatic Intracranial Stenosis. A Meta-analysis of Randomized and Non-randomized Studies
Stroke, 2017Co-Authors: Muhammad F Ishfaq, Emrah Aytac, Sher Afgan, Adnan I. QureshiAbstract:Objective: There is controversy regarding the role of stent placement for the treatment of symptomatic Intracranial Stenosis. Several small trials have inconclusively compared the efficacy of stent...
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A randomized trial comparing primary angioplasty versus stent placement for symptomatic Intracranial Stenosis
Journal of vascular and interventional neurology, 2013Co-Authors: Adnan I. Qureshi, Farhan Siddiq, Saqib A Chaudhry, Shahram Majidi, Gustavo J. Rodriguez, M. Fareed K. SuriAbstract:Background: Both primary angioplasty alone and angioplasty with a self-expanding stent have been compared in non-randomized concurrent clinical studies that suggest equivalent results. However, there is no randomized trial that has compared the two procedures in patients with symptomatic high grade Intracranial Stenosis. Objective: The primary aim of the randomized trial was to compare the clinical and angiographic efficacy of primary angioplasty and angioplasty followed by stent placement in preventing reStenosis, stroke, requirement for second treatment, and death in patients with symptomatic Intracranial Stenosis. Methods: The study prospectively evaluated efficacy and safety of the two existing neurointerventional techniques for treatment of moderate Intracranial Stenosis (Stenosis ≥ 50%) with documented failure of medical treatment or severe Stenosis (≥70%) with or without failure of medical treatment. Results: A total of 18 patients were recruited in the study (mean age [±SD] was 64.7 ± 15.1 years); out of these, 12 were men. Of these 18, 10 were treated with primary angioplasty and 8 were treated with angioplasty followed by self-expanding stent. The technical success rates of Intracranial angioplasty and stent placements defined as ability to achieve
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Intracranial Stenosis in young patients: Unique characteristics and risk factors
Neuroepidemiology, 2012Co-Authors: Farhan Siddiq, Saqib A Chaudhry, Gabriela Vazquez, Mohammad Fareed Khan Suri, Adnan I. QureshiAbstract:Background: Intracranial Stenosis in young patients appears to have different characteristics from that observed in the older population. Objective: To study the
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Abstract 2997: The Severity of Intracranial Stenosis in Anterior Circulation Correlates with Asymmetrical Hemispheric Cerebral Volume on Magnetic Resonance Imaging
Stroke, 2012Co-Authors: Masaki Watanabe, Saqib A Chaudhry, Shahram Majidi, M. Fareed K. Suri, Adnan I. QureshiAbstract:Background and Purpose: Chronic hypoperfusion associated with high grade Intracranial atherosclerosis may results in regional atrophy. This study was performed to determine the effect of Intracranial Stenosis on ipsilateral regional cerebral volume. Methods: We included patients with Intracranial Stenosis >50% in the anterior circulation who underwent brain magnetic resonance image (MRI) who were admitted to a University hospital. The severity of Intracranial atherosclerosis was evaluated by angiography and degree of Stenosis was calculated using the WASID criteria. MRI images were acquired with a 1.5-T MR scanner and fluid attenuated inversion recovery (FLAIR) images were used for volumetric analysis. Volumetric analysis was performed by a single observer with the ANALYZE 9.0 software package. Hemispheric supratentorial volume was defined as hemispheric volume (HV) and included a cumulative value of grey and white matter volumes in frontal, parietal, and occipital lobes. Results: A total 42 hemispheres in 21 patients (12 men, mean age±standard deviation 56.4±16.2 years) with Intracranial Stenosis were studied. There was no statistical difference of HV in between non-stenotic and stenotic side (491.7±62.6 vs 486.7±57.8 cm3, p=0.3953, t-test). There was no statistical difference of HV in between moderate Stenosis (50∼75%) and severe Stenosis (>75%) (480.6±56.7 vs 490.5±60.4 cm3, p=0.3657, t-test). However, in regression analysis, difference between both HV (non stenotic-side - stenotic side HV) within individuals significantly correlated with degree of Stenosis (R2=0.27, P=0.0152). Conclusion: The patients with Intracranial Stenosis of anterior circulation appear to have an asymmetry in regional cerebral volume directly related to the severity of Stenosis. This observation supports the concept that regional cerebral atrophy may be seen with Intracranial Stenosis.
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Abstract 125: A Randomized Trial Comparing Primary Angioplasty versus Stent Placement for Symptomatic Intracranial Stenosis
Stroke, 2012Co-Authors: M. Fareed K. Suri, Farhan Siddiq, Saqib A Chaudhry, Shahram Majidi, Gustavo J. Rodriguez, Adnan I. QureshiAbstract:Introduction: The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) was prematurely terminated due to excessively high rate of stroke and death in patients randomized to Intracranial stent placement. Equivalent results with primary angioplasty in several uncontrolled studies will continue to raise the question that a policy of mandatory stent placement may have led to a higher peri-procedural stroke and death without a clear evidence of incremental benefit. Methods: The primary aim of the study is to compare the clinical and angiographic efficacy of primary angioplasty and angioplasty followed by stent placement in preventing reStenosis, stroke, requirement for second treatment, and death in patients with symptomatic Intracranial Stenosis. The study prospectively evaluated acute,1-month, 6 month, and 1-year efficacy and safety of the two existing neurointerventional techniques for treatment of moderate Intracranial Stenosis (Stenosis ≥50%) with documented failure of medical treatment or severe Stenosis (≥70%) with or without failure of medical treatment. Results: A total of 18 patients were recruited in the study; mean age [±SD] was 64.7±15.1 years, 12 were men. Of these 18, 10 were randomized to primary angioplasty and 8 were randomized to angioplasty followed by self expanding stent. The technical success rates of Intracranial angioplasty and stent placements defined as ability to achieve Conclusions: The trial suggests that a randomized trial comparing primary angioplasty to angioplasty followed by stent placement is feasible. The immediate procedural outcomes with primary angioplasty are comparable to stent placement and warrant further studies.
Colin P Derdeyn - One of the best experts on this subject based on the ideXlab platform.
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Effect of Intracranial Stenosis Revascularization on Dynamic and Static Cerebral Autoregulation.
Journal of vascular and interventional neurology, 2020Co-Authors: Santiago Ortega-gutierrez, Colin P Derdeyn, Edgar A Samaniego, Amy Huang, Arjun Masurkar, Binbin Zheng-lin, David Hasan, Randolph Marshall, Nils PetersenAbstract:Severe Intracranial Stenosis might lead to acute cerebral ischemia. It is imperative to better assess patients who may benefit from immediate reperfusion and blood pressure management to prevent injury to peri-infarct tissue. We assessed cerebral autoregulation using static and dynamic methods in an 81-year-old woman suffering acute cerebral ischemia from severe Intracranial Stenosis in the petrous segment of the left internal carotid artery (LICA). Static cerebral autoregulation, which is evaluated by magnetic resonance imaging and magnetic resonance perfusion studies showed a progression of infarcts and a large perfusion-diffusion mismatch in the entire LICA territory between the second and third days after onset despite maximized medical therapy. Dynamic methods, including transfer function analysis and mean velocity index, demonstrated an increasingly impaired dynamic cerebral autoregulation (DCA) on the affected side between these days. Revascularization through acute Intracranial stenting resulted in improved perfusion in the LICA territory and normalization of both dynamic and static cerebral autoregulation. Thus, DCA, a noninvasive bedside method, may be useful in helping to identify and select patients with large-vessel flow-failure syndromes that would benefit from immediate revascularization of Intracranial atherosclerotic disease.
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Effect of Intracranial Stenosis Revascularization on Dynamic and Static Cerebral Autoregulation
2018Co-Authors: Santiago Ortega-gutierrez, Colin P Derdeyn, Edgar A Samaniego, Amy Huang, Arjun Masurkar, Binbin Zheng-lin, David Hasan, Randolph S. Marshall, Nils H. PetersenAbstract:Severe Intracranial Stenosis might lead to acute cerebral ischemia. It is imperative to better assess patients who may benefit from immediate reperfusion and blood pressure management to prevent injury to peri-infarct tissue. We assessed cerebral autoregulation using static and dynamic methods in an 81-year-old woman suffering acute cerebral ischemia from severe Intracranial Stenosis in the petrous segment of the left internal carotid artery (LICA). Static cerebral autoregulation, evaluated by magnetic resonance imaging and magnetic resonance perfusion studies showed a progression of infarcts and a large perfusion-diffusion mismatch in the entire LICA territory between the second and third days after onset, despite maximized medical therapy. Dynamic methods, including transfer function analysis and mean velocity index, demonstrated an increasingly impaired dynamic cerebral autoregulation (DCA) on the affected side between these days. Revascularization through acute Intracranial stenting resulted in improved perfusion in the LICA territory and normalization of DCA and SCA. Thus DCA, a non-invasive bedside method, may be useful in helping to identify and select patients with large-vessel flow-failure syndromes that would benefit from immediate revascularization of Intracranial atherosclerotic disease.
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does the stenting versus aggressive medical therapy trial support stenting for subgroups with Intracranial Stenosis
Stroke, 2015Co-Authors: Helmi L. Lutsep, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Bethany F Lane, Tanya N. Turan, Jean Montgomery, Scott L Janis, Marc I ChimowitzAbstract:Background and Purpose— Although the Stenting Versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial showed that medical therapy alone was superior to stenting plus medical therapy for preventing recurrent strokes in patients with symptomatic Intracranial Stenosis, we determined whether SAMMPRIS supported the use of stenting in any subpopulations of patients with symptomatic Intracranial arterial Stenosis. Methods— The primary outcome, 30-day stroke and death and later strokes in the territory of the qualifying artery, was compared in those with and without baseline factors in the 2 treatment arms, percutaneous transluminal angioplasty and stenting (PTAS) plus aggressive medical therapy versus aggressive medical therapy alone. Baseline factors included sex, age, race, diabetes mellitus, hypertension, lipid disorder, smoking status, type of qualifying event, qualifying event hypoperfusion symptoms, use of antithrombotic or proton pump inhibitor at baseline, days to enrollment, old infarcts in the same territory, percent Stenosis, other artery Stenosis, and location of the symptomatic artery. Results— A total of 451 patients were enrolled, 227 randomized to aggressive medical therapy and 224 to PTAS. Of all variables evaluated, the observed 2-year event rates were higher with PTAS than with aggressive medical therapy in the vast majority and the interaction with treatment was not statistically significant for any of the factors. Conclusions— The SAMMPRIS results do not provide evidence to support the use of PTAS using the Wingspan stent system compared with medical treatment in any examined subpopulation of patients with symptomatic Intracranial Stenosis, including those with qualifying event hypoperfusion symptoms. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00576693.
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Stenting in Intracranial Stenosis: Current Controversies and Future Directions
Current Atherosclerosis Reports, 2015Co-Authors: Arindam R. Chatterjee, Colin P DerdeynAbstract:Angioplasty and stenting for Intracranial atherosclerotic Stenosis (ICAS) are a last resort for patients with high-grade Intracranial Stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.
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Treatment Trends In Management Of Intracranial Stenosis In The Pre- And Post-Sammpris Era (I8-1.008)
Neurology, 2014Co-Authors: Swaroop Pawar, Michael J. Lynn, George A Cotsonis, Colin P Derdeyn, David Fiorella, Tanya N. Turan, Rahim H. Wooley, Barney J. Stern, Marc I ChimowitzAbstract:BACKGROUND: Treatment of Intracranial Stenosis has evolved over the course of the last 2 decades. This survey sought to define the impact of, ‘Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS)’ an NIH-sponsored clinical trial on treatment trends of physicians in managing Intracranial Stenosis. METHODS: Surveys of treatment choices were sent 1 year post-publication of the SAMMPRIS Trial results. (2012). A similar survey designed in the Post- Warfarin Vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial Era, another NIH-sponsored clinical trial was used to compare treatment trends (pre-SAMMPRIS survey). Both the surveys were sent to neurologists as well as neurointerventionists. The post-SAMMPRIS survey addressed questions regarding the maximum benefit physicians would require to recommend a new endovascular treatment to their patients. Data was analyzed using the chi-square tests. RESULTS: Post-SAMMPRIS, the number of respondents recommending antiplatelet treatment for Intracranial Stenosis increased. Compared to the post-WASID/pre-SAMMPRIS respondents, more post-SAMMPRIS respondents preferred antiplatelet agents for Stenosis in the anterior circulation (85% vs. 94%, p=0.0017) and posterior circulation (74% vs. 83%, p=0.0145). The antiplatelet agent most post-SAMMPRIS was the combination of aspirin and clopidogrel. The percentage of neurologists who recommended percutaneous transluminal angioplasty and stenting (PTAS) in > 25% of ICAS patients decreased from pre-SAMMPRIS (12%) to post-SAMMPRIS (6%), while for neurointerventionists, it decreased from (49%) to (17%). DISCUSSION: SAMMPRIS had a major impact on treatment trends of physicians managing patients with Intracranial Stenosis. In the Post-SAMMPRIS survey, 91% of respondents participating in SAMMPRIS and 82% of overall respondents indicated that the SAMMPRIS results changed the way they managed patients with ICAS.As aggressive medical management coupled with optimal risk factor reduction shows promise in reducing rates of recurrent stroke, a novel endovascular therapy will have to seek newer heights of increasing RRR to gain acceptance by practitioners. Disclosure: Dr. Pawar has nothing to disclose. Dr. Turan has received personal compensation for activities with Gore Laboratories Inc., and Boehringer Ingelheim Pharmaceuticals Inc. Dr. Turan has received research support from Stryker Co., the National Institutes of Health, and AstraZeneca. Dr. Cotsonis has nothing to disclose. Dr. Lynn has nothing to disclose. Dr. Wooley has nothing to disclose. Dr. Stern has received personal compensation for activities with Lippincott Williams & Wilkins. Dr. Stern has received personal compensation in an editorial capacity for The Neurologist. Dr. Derdeyn has received personal compensation for activities with W.L. Gore and Associates, Boston Scientific Corporation, and Target Therapeutics. Dr. Fiorella has received personal compensation for activities with Covidien/ev3, Codman/Micrus/JNJ, NFocus, Vascular Simulations, CSVL, Microvention/Terumo, and Siemens Medical Imaging. Dr. FIorella has received royalty, or license fee, or contractual rights payments from Codman/Micrus/JNJ. Dr. Fiorella has received research support from Microvention and Siemens Medical Imaging. Dr. Chimowitz has received personal compensation for activities with Axio Research, Merck & Co. Inc., and Gore. Dr. Chimowitz has received research support from the National Institute of Neurological Disorders and Stroke, Stryker, and Boston Scientific Corporation.
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what threshold defines penumbral brain tissue in patients with symptomatic anterior circulation Intracranial Stenosis an exploratory analysis
Journal of Neuroimaging, 2019Co-Authors: Shadi Yaghi, Shyam Prabhakaran, David S. Liebeskind, Mahesh V Jayaraman, Pooja Khatri, Sharon D Yeatts, Shawna Cutting, Andrew D Chang, Daniel Sacchetti, Karen FurieAbstract:BACKGROUND AND PURPOSE: Impaired distal perfusion predicts neurological deterioration in large artery atherosclerosis. We aim to determine the optimal threshold of Tmax delay on perfusion imaging that is associated with neurological deterioration in patients with symptomatic proximal anterior circulation large artery Stenosis. METHODS: Data were abstracted from a prospective ischemic stroke database of consecutively enrolled patients with symptomatic proximal Intracranial Stenosis (internal carotid artery or M1 segment of the middle cerebral artery) who underwent magnetic resonance perfusion imaging within 24 hours of symptom onset during a 15-month period. Tissue volumes of perfusion delay Tmax 0-4 seconds, Tmax > 4 seconds, Tmax > 6 seconds, and Tmax > 8 seconds were calculated using an automated approach. A target mismatch (penumbra-core) was defined as ≥15mL of brain tissue using each of the Tmax threshold categories. The outcome was neurological deterioration at 30 days defined as new or worsening neurological deficits that are not attributed to a nonvascular etiology. RESULTS: Among 52 patients with symptomatic Intracranial Stenosis, 26 patients met inclusion criteria. Neurological deterioration was associated with target mismatch profile defined according to Tmax > 6 seconds (66.7% [6/9] vs. 5.9% [1/17], P 8 seconds (57.1% [4/7] vs. 15.8% [3/19], P = .05] but not according to Tmax > 4 seconds (27.3% [6/17] vs. 11.1% [1/9], P = .35]. CONCLUSIONS: A target mismatch profile using Tmax > 6 seconds may define tissue at risk in patients with acute symptomatic proximal anterior circulation Intracranial Stenosis. More studies are needed to confirm our findings.
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What Threshold Defines Penumbral Brain Tissue in Patients with Symptomatic Anterior Circulation Intracranial Stenosis: An Exploratory Analysis.
Journal of Neuroimaging, 2018Co-Authors: Shadi Yaghi, Shyam Prabhakaran, David S. Liebeskind, Mahesh V Jayaraman, Pooja Khatri, Sharon D Yeatts, Shawna Cutting, Andrew D Chang, Daniel Sacchetti, Karen FurieAbstract:Impaired distal perfusion predicts neurological deterioration in large artery atherosclerosis. We aim to determine the optimal threshold of Tmax delay on perfusion imaging that is associated with neurological deterioration in patients with symptomatic proximal anterior circulation large artery Stenosis. Data were abstracted from a prospective ischemic stroke database of consecutively enrolled patients with symptomatic proximal Intracranial Stenosis (internal carotid artery or M1 segment of the middle cerebral artery) who underwent magnetic resonance perfusion imaging within 24 hours of symptom onset during a 15-month period. Tissue volumes of perfusion delay Tmax 0-4 seconds, Tmax > 4 seconds, Tmax > 6 seconds, and Tmax > 8 seconds were calculated using an automated approach. A target mismatch (penumbra-core) was defined as ≥15mL of brain tissue using each of the Tmax threshold categories. The outcome was neurological deterioration at 30 days defined as new or worsening neurological deficits that are not attributed to a nonvascular etiology. Among 52 patients with symptomatic Intracranial Stenosis, 26 patients met inclusion criteria. Neurological deterioration was associated with target mismatch profile defined according to Tmax > 6 seconds (66.7% [6/9] vs. 5.9% [1/17], P < .01) and Tmax >8 seconds (57.1% [4/7] vs. 15.8% [3/19], P = .05] but not according to Tmax > 4 seconds (27.3% [6/17] vs. 11.1% [1/9], P = .35]. A target mismatch profile using Tmax > 6 seconds may define tissue at risk in patients with acute symptomatic proximal anterior circulation Intracranial Stenosis. More studies are needed to confirm our findings. © 2018 by the American Society of Neuroimaging.
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decreased signal intensity ratio on mra reflects misery perfusion on spect in patients with Intracranial Stenosis
Journal of Neuroimaging, 2018Co-Authors: Masatomo Miura, David S. Liebeskind, Makoto Nakajima, Akiko Fujimoto, Shinya Shiraishi, Yukio AndoAbstract:BACKGROUND AND PURPOSE: Acetazolamide reactivity on 123 I-IMP SPECT is used to detect misery perfusion due to Intracranial atherosclerosis. Noninvasive fractional flow assessed by signal intensity ratio (SIR) on time of flight-magnetic resonance angiography (TOF-MRA) might offer a feasible alternative to identify high-risk Intracranial Stenosis. METHODS: Data from consecutive patients with unilateral middle cerebral artery (MCA) Stenosis who underwent both TOF-MRA and acetazolamide reactivity on 123 I-IMP SPECT were retrospectively analyzed. Signal intensity was measured in the background and on the MCA proximal and distal to the stenotic lesion on TOF-MRA. Mean cerebral blood flow (CBF) at rest and cerebrovascular reactivity were measured in the target MCA territory. CBF patterns of the MCA were divided into three groups (Powers' stage 0-II). RESULTS: A total of 56 sets of diagnostic imaging in 33 patients were assessed. Four CBF patterns were stage II in four MCA territories, stage I in 31, and stage 0 in 21. Median SIR of the MCA was .53 (interquartile range .46-.69) for stage II, .78 (.63-.90) for stage I, and .91 (.85-.95) for stage 0. The optimal cutoff for SIR obtained from receiver operating characteristic curve analysis to predict stage II was < .56. CONCLUSIONS: In patients with unilateral MCA Stenosis, decreased SIR was correlated with misery perfusion, providing a simpler, widely available predictor of high-risk Intracranial Stenosis.
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Decreased Signal Intensity Ratio on MRA Reflects Misery Perfusion on SPECT in Patients with Intracranial Stenosis
Journal of Neuroimaging, 2017Co-Authors: Masatomo Miura, David S. Liebeskind, Makoto Nakajima, Akiko Fujimoto, Shinya Shiraishi, Yukio AndoAbstract:Acetazolamide reactivity on 123 I-IMP SPECT is used to detect misery perfusion due to Intracranial atherosclerosis. Noninvasive fractional flow assessed by signal intensity ratio (SIR) on time of flight-magnetic resonance angiography (TOF-MRA) might offer a feasible alternative to identify high-risk Intracranial Stenosis. Data from consecutive patients with unilateral middle cerebral artery (MCA) Stenosis who underwent both TOF-MRA and acetazolamide reactivity on 123 I-IMP SPECT were retrospectively analyzed. Signal intensity was measured in the background and on the MCA proximal and distal to the stenotic lesion on TOF-MRA. Mean cerebral blood flow (CBF) at rest and cerebrovascular reactivity were measured in the target MCA territory. CBF patterns of the MCA were divided into three groups (Powers' stage 0-II). A total of 56 sets of diagnostic imaging in 33 patients were assessed. Four CBF patterns were stage II in four MCA territories, stage I in 31, and stage 0 in 21. Median SIR of the MCA was .53 (interquartile range .46-.69) for stage II, .78 (.63-.90) for stage I, and .91 (.85-.95) for stage 0. The optimal cutoff for SIR obtained from receiver operating characteristic curve analysis to predict stage II was < .56. In patients with unilateral MCA Stenosis, decreased SIR was correlated with misery perfusion, providing a simpler, widely available predictor of high-risk Intracranial Stenosis. Copyright © 2017 by the American Society of Neuroimaging.
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noninvasive fractional flow on mra predicts stroke risk of Intracranial Stenosis
Journal of Neuroimaging, 2015Co-Authors: David S. Liebeskind, Michael J. Lynn, Marc I Chimowitz, Andrzej S. Kosinski, Fabien Scalzo, Albert K Fong, Pari Fariborz, Edward FeldmannAbstract:BACKGROUND AND PURPOSE Fractional flow may identify hemodynamic effects and ischemic risk beyond percent Stenosis of an artery. We hypothesized that diminished TOF-MRA signal intensity distal to an Intracranial Stenosis predicts stroke risk. METHODS TOF-MRA was acquired prospectively in the SONIA-WASID trials. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest, blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures to identify predictors for risk of stroke in the territory. RESULTS 189 patients with 50-99% symptomatic Intracranial Stenosis in SONIA-WASID had TOF-MRA available. In univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < .9 was 5.2 (1.8, 15.3; P < .001) as compared to SIR ≥ .9. Multivariate analysis correcting for baseline systolic blood pressure, LDL, centrally measured percent Stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < .9 was 10.9 (2.0, 58.9; P < .001). In those with <70% Stenosis, a SIR < .9 maintained a significant association with recurrent stroke in the territory (P = .006), with a 2-year event rate of 17.3%. CONCLUSIONS Fractional flow assessed by TOF-MRA SIR may be a useful noninvasive tool to identify high-risk Intracranial lesions. CLINICAL TRIAL REGISTRATION-URL This trial was not registered because enrollment began prior to July 1, 2005.