Diagnosis and neurosurgical treatment of intracranial vascular occlusive syndromes

Article
  • 37 Downloads

Opinion statement

Intracranial atherosclerosis represents the most prevalent form of intracranial vascular occlusive disease in the adult population and is a major contributor to is chemic stroke. The most reliable method for diagnosing intracranial stenosis relies on conventional catheter angiography; MRI and CT imaging and transcranial Doppler currently are valuable screening tools, and ongoing advances in these modalities may render angiography nonessential for accurate diagnosis in the future. Given the potential for hemodynamic compromise from intracranial occlusive disease, a variety of imaging modalities may be used to assess the adequacy of cerebral perfusion, relying on direct measurements of oxygen extraction fraction or the response to vasodilatory stimuli to determine hemodynamic status. The modalities are well established for assessing the anterior circulation but have proven less useful for the posterior circulation, in which direct measurements of large vessel flow using quantitative magnetic resonance angiography may be more valuable. Surgical and endovascular interventions for treating intracranial stenosis are not, as of yet, proven therapies for routine management. Extracranial-intracranial bypass surgery and endovascular angioplasty and stenting are being investigated in randomized trials to evaluate their efficacy in treating intracranial vascular occlusive disease.

References and Recommended Reading

  1. 1.
    Wityk RJ, Lehman D, Klag M, et al.: Race and sex differences in the distribution of cerebral atherosclerosis. Stroke 1996, 27:1974–1980.PubMedGoogle Scholar
  2. 2.
    Sacco RL, Kargman DE, Gu Q, et al.: Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke 1995, 26:14–20.PubMedGoogle Scholar
  3. 3.
    Feldmann E, Daneault N, Kwan E, et al.: Chinese-white differences in the distribution of occlusive cerebrovascular disease. Neurology 1990, 40:1541–1545.PubMedGoogle Scholar
  4. 4.
    Huang YN, Gao S, Li SW, et al.: Vascular lesions in Chinese patients with transient ischemic attacks. Neurology 1997, 48:524–525.PubMedGoogle Scholar
  5. 5.
    Suzuki J, Takaku A: Cerebrovascular “moyamoya” disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol 1969, 20:288–299.PubMedGoogle Scholar
  6. 6.
    Pryor JC, Setton A, Nelson PK, Berenstein A: Complications of diagnostic cerebral angiography and tips on avoidance. Neuroimaging Clin N Am 1996, 6:751–758.PubMedGoogle Scholar
  7. 7.
    Sohn CH, Sevick RJ, Frayne R: Contrast-enhanced MR angiography of the intracranial circulation. Magn Reson Imaging Clin N Am 2003, 11:599–614.PubMedCrossRefGoogle Scholar
  8. 8.
    Feldmann E, Wilterdink JL, Kosinski A, et al.: The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) trial. Neurology 2007, 68:2099–2106.PubMedCrossRefGoogle Scholar
  9. 9.
    Houkin K, Aoki T, Takahashi A, Abe H: Diagnosis of moyamoya disease with magnetic resonance angiography. Stroke 1994, 25:2159–2164.PubMedGoogle Scholar
  10. 10.
    Derdeyn CP, Grubb RL Jr, Powers WJ: Cerebral hemodynamic impairment: methods of measurement and association with stroke risk. Neurology 1999, 53:251–259.PubMedGoogle Scholar
  11. 11.
    Kuroda S, Houkin K, Kamiyama H, et al.: Long-term prognosis of medically treated patients with internal carotid or middle cerebral artery occlusion: can acetazolamide test predict it? Stroke 2001, 32:2110–2116.PubMedCrossRefGoogle Scholar
  12. 12.
    Ogasawara K, Ogawa A, Yoshimoto T: Cerebrovascular reactivity to acetazolamide and outcome in patients with symptomatic internal carotid or middle cerebral artery occlusion: a xenon-133 single-photon emission computed tomography study. Stroke 2002, 33:1857–1862.PubMedCrossRefGoogle Scholar
  13. 13.
    Vernieri F, Pasqualetti P, Passarelli F, et al.: Outcome of carotid artery occlusion is predicted by cerebrovascular reactivity. Stroke 1999, 30:593–598.PubMedGoogle Scholar
  14. 14.
    Yokota C, Hasegawa Y, Minematsu K, Yamaguchi T: Effect of acetazolamide reactivity on [corrected] long-term outcome in patients with major cerebral artery occlusive diseases. Stroke 1998, 29:640–644.PubMedGoogle Scholar
  15. 15.
    Grubb RL Jr, Derdeyn CP, Fritsch SM, et al.: Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 1998, 280:1055–1060.PubMedCrossRefGoogle Scholar
  16. 16.
    Yamauchi H, Fukuyama H, Nagahama Y, et al.: Significance of increased oxygen extraction fraction in five-year prognosis of major cerebral arterial occlusive diseases. J Nucl Med 1999, 40:1992–1998.PubMedGoogle Scholar
  17. 17.
    Nemoto EM, Yonas H, Kuwabara H, et al.: Identification of hemodynamic compromise by cerebrovascular reserve and oxygen extraction fraction in occlusive vascular disease. J Cereb Blood Flow Metab 2004, 24:1081–1089.PubMedCrossRefGoogle Scholar
  18. 18.
    Haase J, Magnussen IB, Ogilvy CS, et al.: Evaluating patients with vertebrobasilar transient ischemic attacks. Surg Neurol 1999, 52:386–392.PubMedCrossRefGoogle Scholar
  19. 19.
    Guppy KH, Charbel FT, Corsten LA, et al.: Hemodynamic evaluation of basilar and vertebral artery angioplasty. Neurosurgery 2002, 51:327–333; discussion 333–324.PubMedCrossRefGoogle Scholar
  20. 20.
    Hendrikse J, van Raamt AF, van der Graaf Y, et al.: Distribution of cerebral blood flow in the circle of Willis. Radiology 2005, 235:184–189.PubMedCrossRefGoogle Scholar
  21. 21.
    Zhao M, Charbel FT, Alperin N, et al.: Improved phase-contrast flow quantification by three-dimensional vessel localization. Magn Reson Imaging 2000, 18:697–706.PubMedCrossRefGoogle Scholar
  22. 22.
    Amin-Hanjani S, Du X, Zhao M, et al.: Use of quantitative magnetic resonance angiography to stratify stroke risk in symptomatic vertebrobasilar disease. Stroke 2005, 36:1140–1145.PubMedCrossRefGoogle Scholar
  23. 23.
    Zipfel GJ, Fox DJ Jr, Rivet DJ: Moyamoya disease in adults: the role of cerebral revascularization. Skull Base 2005, 15:27–41.PubMedCrossRefGoogle Scholar
  24. 24.
    Kuroda S, Houkin K: Moyamoya disease: current concepts and future perspectives. Lancet Neurol 2008, 7:1056–1066.PubMedCrossRefGoogle Scholar
  25. 25.
    Houkin K, Kuroda S, Nakayama N: Cerebral revascularization for moyamoya disease in children. Neurosurg Clin N Am 2001, 12:575–584, ix.PubMedGoogle Scholar
  26. 26.
    Ausman JI, Diaz FG, Sadasivan B, Dujovny M: Intracranial vertebral endarterectomy. Neurosurgery 1990, 26:465–471.PubMedCrossRefGoogle Scholar
  27. 27.
    Jacobson JH 2nd, Wallman LJ, Schumacher GA, et al.: Microsurgery as an aid to middle cerebral artery endarterectomy. Microsurgery 1992, 13:112–117; discussion 117–118.PubMedCrossRefGoogle Scholar
  28. 28.
    Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. N Engl J Med 1985, 313:1191–1200.Google Scholar
  29. 29.
    Goldring S, Zervas N, Langfitt T: The Extracranial-Intracranial Bypass Study. A report of the committee appointed by the American Association of Neurological Surgeons to examine the study. N Engl J Med 1987, 316:817–820.PubMedGoogle Scholar
  30. 30.
    Sundt TM Jr: Was the international randomized trial of extracranial-intracranial arterial bypass representative of the population at risk? N Engl J Med 1987, 316:814–816.PubMedGoogle Scholar
  31. 31.
    Grubb RL Jr, Powers WJ, Derdeyn CP, et al.: The carotid occlusion surgery study. Neurosurg Focus 2003, 14:e9.PubMedCrossRefGoogle Scholar
  32. 32.
    Mizumura S, Nakagawara J, Takahashi M, et al.: Three-dimensional display in staging hemodynamic brain ischemia for JET study: objective evaluation using SEE analysis and 3D-SSP display. Ann Nucl Med 2004, 18:13–21.PubMedCrossRefGoogle Scholar
  33. 33.
    Ozgur BM, Aryan HE, Levy ML: Indirect revascularisation for paediatric moyamoya disease: the EDAMS technique. J Clin Neurosci 2006, 13:105–108.PubMedCrossRefGoogle Scholar
  34. 34.
    Isono M, Ishii K, Kamida T, et al.: Long-term outcomes of pediatric moyamoya disease treated by encephalo-duroarterio-synangiosis. Pediatr Neurosurg 2002, 36:14–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Srinivasan J, Britz GW, Newell DW: Cerebral revascularization for moyamoya disease in adults. Neurosurg Clin N Am 2001, 12:585–594, ix.PubMedGoogle Scholar
  36. 36.
    Ishikawa T, Houkin K, Kamiyama H, Abe H: Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease. Stroke 1997, 28:1170–1173.PubMedGoogle Scholar
  37. 37.
    Horn P, Scharf J, Pena-Tapia P, Vajkoczy P: Risk of intraoperative ischemia due to temporary vessel occlusion during standard extracranial-intracranial arterial bypass surgery. J Neurosurg 2008, 108:464–469.PubMedCrossRefGoogle Scholar
  38. 38.
    Regli L, Piepgras DG, Hansen KK: Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation. J Neurosurg 1995, 83:806–811.PubMedGoogle Scholar
  39. 39.
    Stiver SI, Ogilvy CS: Acute hyperperfusion syndrome complicating EC-IC bypass. J Neurol Neurosurg Psychiatry 2002, 73:88–89.PubMedCrossRefGoogle Scholar
  40. 40.
    Fujimura M, Mugikura S, Kaneta T, et al.: Incidence and risk factors for symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with moyamoya disease. Surg Neurol 2008 May 29 (Epub ahead of print).Google Scholar
  41. 41.
    Langer DJ, Van Der Zwan A, Vajkoczy P, et al.: Excimer laser-assisted nonocclusive anastomosis. An emerging technology for use in the creation of intracranial-intracranial and extracranial-intracranial cerebral bypass. Neurosurg Focus 2008, 24:E6.PubMedCrossRefGoogle Scholar
  42. 42.
    Klijn CJ, Kappelle LJ, van der Zwan A, et al.: Excimer laser-assisted high-flow extracranial/intracranial bypass in patients with symptomatic carotid artery occlusion at high risk of recurrent cerebral ischemia: safety and long-term outcome. Stroke 2002, 33:2451–2458.PubMedCrossRefGoogle Scholar
  43. 43.
    Hopkins LN, Budny JL: Complications of intracranial bypass for vertebrobasilar insufficiency. J Neurosurg 1989, 70:207–211.PubMedCrossRefGoogle Scholar
  44. 44.
    Ausman JI, Diaz FG, Vacca DF, Sadasivan B: Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency. J Neurosurg 1990, 72:554–558.PubMedGoogle Scholar
  45. 45.
    Chimowitz MI, Lynn MJ, Howlett-Smith H, et al.: Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005, 352:1305–1316.PubMedCrossRefGoogle Scholar
  46. 46.
    Kasner SE, Chimowitz MI, Lynn MJ, et al.: Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation 2006, 113:555–563.PubMedCrossRefGoogle Scholar
  47. 47.
    Marks MP, Wojak JC, Al-Ali F, et al.: Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke 2006, 37:1016–1020.PubMedCrossRefGoogle Scholar
  48. 48.
    Fiorella D, Levy EI, Turk AS, et al.: US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 2007, 38:881–887.PubMedCrossRefGoogle Scholar
  49. 49.
    Zaidat OO, Klucznik R, Alexander MJ, et al.: The NIH registry on use of the Wingspan stent for symptomatic 70–99% intracranial arterial stenosis. Neurology 2008, 70:1518–1524.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group, LLC 2009

Authors and Affiliations

  1. 1.Neuropsychiatric InstituteUniversity of Illinois at ChicagoChicagoUSA

Personalised recommendations