HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by du Mesnil de Rochemont, R. Articles by Berkefeld, J. Search for Related Content PubMed PubMed Citation Articles by du Mesnil de Rochemont, R. Articles by Berkefeld, J.

Recurrent Symptomatic High-Grade Intracranial Stenoses: Safety and Efficacy of Undersized Stents— Initial Experience¹

¹ From the Institute of Neuroradiology (R.d.M.d.R., B.T., F.E.Z., J.B.) and Department of Neurology (M.B., M.S.), Johann Wolfgang Goethe-University Frankfurt, Schleusenweg 2–16, 60528 Frankfurt, Germany. Received February 4, 2003; revision requested April 23; final revision received September 5; accepted September 29. Address correspondence to R.d.M.d.R. (e-mail: mesnil@em.uni-frankfurt.de).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To prospectively evaluate the safety and efficacy of undersized stents used in patients with high-grade intracranial stenosis and recurrent ischemic symptoms who are undergoing medical treatment.

MATERIALS AND METHODS: In 18 patients (13 men, five women; age range, 51–82 years), 20 high-grade (>70%) intracranial stenoses were selected for stent placement. All patients had transient ischemic symptoms or minor strokes while undergoing combined antithrombotic therapy with acetylsalicylic acid plus clopidogrel or anticoagulation therapy with warfarin or heparin plus acetylsalicylic acid. Technical success was defined as reaching the target lesion and deploying a stent, with a residual stenosis of less than 50%. The diameter of the stent was 0.5-mm smaller than the measured diameter of the normal adjacent vessel to avoid dissection and vessel rupture. Primary endpoints for safety evaluation were the combined incidence of death or major or minor stroke at 30 days; for efficacy evaluation, the primary endpoint was the incidence of any stroke in the treated vascular territory within the first 6 months. Statistical evaluation of the reduction of stenosis was performed.

RESULTS: In 18 of 20 stenoses, a stent was placed and the degree of stenosis was reduced from a median of 82% (range, 72%–97%) to a median of 16% (5%–40%; P < .001). The technical success rate was 90%. One patient had a parenchymal hemorrhage in a preexisting infarct on the 2nd day. Thus, the 30-day combined stroke and death rate was 6%. No immediate complication, thromboembolism, dissection compromising blood flow, or vessel rupture occurred during these procedures. Within the first 6 months after intervention, no patient had new ischemic symptoms in the treated vascular territory.

CONCLUSION: In selected patients with recurrent ischemic events due to high-grade intracranial stenosis, undersized stent placement holds promise as an effective and safe procedure.

© RSNA, 2004

Index terms: Brain, ischemia, 17.769 • Cerebral blood vessels, stenosis or obstruction, 172.721, 174.721, 175.721 • Cerebral blood vessels, transluminal angioplasty, 17.1269 • Cerebral blood vessels, US, 17.12989 • Stents and prostheses

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Intracranial atherosclerotic stenoses contribute to 5%–10% of ischemic strokes (1). Medical therapy consists of antithrombotic therapy with antiplatelet agents or anticoagulation, as well as the reduction of vascular risk factors (2). Patients undergoing medical treatment who experience recurrent ischemic symptoms may have a poor prognosis, with a rate of ischemic events of up to 50% within the first 2 years (3).

As an alternative, various revascularization strategies have been suggested during the past decades, but the method of choice is still controversial. Extracranial-intracranial bypass surgery has been found to be unbeneficial in patients with intracranial stenoses (4). Balloon angioplasty procedures of intracranial stenoses have been performed since the 1980s (5), but initial experiences were associated with a high risk of periinterventionalstroke and death. Technical advances in catheter and balloon technology with more flexible devices, which enable engagement of the curves of the carotid siphon and vertebral artery, have boosted new attempts in the 1990s, but the results of balloon angioplasty are still not always predictable and are associated with severe complications such as dissection, local thrombosis, or vessel rupture (6). The safety has been improved by using slightly undersized balloons to avoid these complications (7,8).

Another positive step has been the development of flexible balloon-expandable stents; articles on several case series have shown the technical feasibility of intracranial stent placement (9–11). The recoil of stenosis following angioplasty can be diminished by stent placement, but severe complications (especially vessel rupture) are still reported (12,13). The benefit-risk ratio of endovascular revascularization remains in dispute (2,14).

The purpose of our study was to prospectively evaluate the safety and efficacy of undersized stents in patients with high-grade intracranial stenoses and recurrent ischemic symptoms who are undergoing medical treatment.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Patients
Between March 22, 2001, and October 10, 2002, 18 patients with an age range of 51–82 years (median, 66 years) were scheduled to undergo elective stent placement for intracranial atherosclerotic stenosis. There were 13 men (age range, 51–74 years; median, 64 years) and five women (age range, 63–82 years; median, 71 years). Inclusion criteria were as follows: atherosclerotic stenosis of between 70% and 99% luminal narrowing, as depicted at angiography (reference diameter was that of the normal vessel segment distal to the stenotic lesion) (1); and recurrent ischemic events with either transient ischemic attacks or minor strokes in the territory of the stenosed intracranial vessel (2). Ischemic events occurred while patients were undergoing medical treatment consisting of coumadin (international normalized ratio, or INR, 2.0–3.0) plus acetylsalicylic acid (100 mg/d) in three patients, unfractionated intravenously administered heparin (two- or threefold prolongation of activated partial thromboplastin time) plus acetylsalicylic acid (100 mg/d) in 12 patients, or clopidogrel (75 mg/d) plus acetylsalicylic acid (100 mg/d) in three patients. The medical therapy had to have been initiated at least 10 days before the recurrent event qualifying for stent placement. Thus, only patients who failed antithrombotic therapy were treated. The interventional procedure was performed as soon as possible after the qualifying ischemic event. All patients underwent a full neurologic evaluation and transcranial duplex ultrasonographic (US) examination prior to vascular intervention. An interdisciplinary conference of neurologists and interventional neuroradiologists determined the indication for intracranial stent placement. The patients were informed of our investigational procedures, and they gave written informed consent according to the guidelines of the local ethics committee that approved our study.

In 18 patients, there were 20 high-grade intracranial stenoses; the median grade of stenosis was 82% (range, 72%–97%) and the width of the residual lumen was less than 1 mm. Eleven lesions were located in the vertebrobasilar system (six in the vertebral and five in the basilar artery). The remaining nine stenoses were located in the anterior circulation (seven in the intracranial internal carotid artery and two in the M1 segment of the middle cerebral artery). After hospital discharge, all patients were scheduled for follow-up evaluations at 3, 6, 12 and 24 months; follow-up evaluation included clinical and transcranial duplex US examinations performed by vascular neurologists (M.B. or M.S.). In seven patients, follow-up angiography was performed after 6 months.

Interventional Procedure
All procedures were performed with use of a general anesthetic. A 6-F guiding catheter was placed in the high cervical portion of the artery to be treated. The diameter of the residual lumen of the stenosis, the length of the stenosis, and the normal vessel adjacent were measured by using data sets from three-dimensional rotation angiography (Integris; Philips Medical Systems, Eindhoven, the Netherlands). With the angiographic images used as road maps, a micro–guide wire (Prowler 14; Cordis, Miami, Fla) and microcatheter (Transend X; Target Therapeutics/Boston Scientific, Freemont, Calif) were first passed through the stenosis. After distal placement of the microcatheter, the micro–guide wire was replaced with a 3-m cardiac floppy exchange wire (CHOICE PT; Boston Scientific, Galway, Ireland). The microcatheter was exchanged for the delivery catheter of the balloon-expandable stent (INX [n = 16] or S670 [n = 2]; Medtronic, Minneapolis, Minn). With use of measurements derived from three-dimensional rotation angiography, the diameter of the stent was chosen to be 0.5 mm smaller than the measured diameter of the normal adjacent vessel. We therefore called the stent "undersized" compared with the normal adjacent vessel, and the artery walls were not straight after stent placement. No other connotations of "undersized" are implied. The stent was deployed and expanded by inflating the balloon of the delivery system to the nominal diameter. In three cases, in which there were very small residual lumina, we performed dilation of 2 mm by using a percutaneous transluminal coronary angioplasty balloon (Ranger; Boston Scientific, Watertown, Mass) before stent placement. Angiography was performed before the guide wire and guiding catheter were retrieved. Two patients had tandem intracranial stenoses, which were treated with the placement of two stents during the same session. In two other patients, additional bifurcated carotid stenoses were treated with stents to get access to the subsequent intracranial carotid stenosis. All interventional procedures were performed by one of two interventional neuroradiologists (R.d.M.d.R. or J.B., 4 and 7 years of experience in interventional neuroradiology, respectively).

Transcranial Duplex US
For noninvasive diagnosis and follow-up evaluation of the intracranial stenoses, we performed transcranial color-coded duplex US (Elegra Advanced, 2.5-MHz 90° sector scanner; Siemens Medical Systems, Erlangen, Germany) examinations. The examinations were performed by two experienced neurosonologists (M.B. or M.S.). For the internal carotid artery and the proximal middle cerebral artery, we used a peak systolic velocity threshold of 220 cm/sec to diagnose a stenosis of 50% or more; the corresponding thresholds were 140 cm/sec for the basilar artery and 120 cm/sec for the vertebral artery (15). Transcranial color-coded duplex US was performed at each follow-up evaluation.

Medical Treatment
Medical treatment with clopidogrel (75 mg/d) and acetylsalicylic acid (100 mg/d) was initiated at least 3 days before the intervention and was continued for at least 6 months. The activated clotting time was measured before the procedure and an adapted heparin bolus (intended activated clotting time, 300 seconds) was administered. In the first nine patients treated, administration of heparin was continued for 48 hours. The last nine patients received only a periinterventional heparin bolus because of a complication that was encountered in patient 9. All patients were continuously monitored in a neurologic intermediate care unit for the first 24–48 hours after intervention. Blood pressure was maintained within the normal reference range (120–140 mm Hg systolic) during this time. To achieve this, we used intravenously administered urapidil in hypertensive patients and plasma expander plus isotonic fluid in hypotensive patients; none of the patients received catecholamines to maintain blood pressure. In patients with a history of arterial hypertension, oral antihypertensive medication regimens were resumed thereafter.

Technical Success
Technical success was defined as reaching the target lesion and deploying a stent, with a residual stenosis of less than 50% (evaluated by R.d.M.d.R. and J.B. by consensus). The degree of stenosis was evaluated electronically at angiography by measuring the exact diameter of the stenosis and the normal adjacent vessel segment before stent deployment and of the treated segment and the adjacent vessel segment after stent deployment. The percentage of stenosis was defined as follows: 1 - (D_SS/D_AV), where D_SS is the diameter of the stenosed segment and D_AV is the diameter of the adjacent vessel segment. Statistical evaluation of the reduction of stenosis was performed.

Safety Evaluation
The primary safety endpoint was the combined incidence of death or major or minor stroke at 30 days, which was evaluated by two stroke neurologists (M.B. or M.S.). Secondary endpoints were the vascular outcomes, which were evaluated on angiograms (R.d.M.d.R. and J.B. by consensus) and included rates of vessel rupture, dissection compromising blood flow, and thrombembolic events.

Efficacy Evaluation
The primary efficacy endpoint was incidence of stroke in the treated vascular territory during the 6-month follow-up period, which was evaluated by the two stroke neurologists. The secondary endpoint was the rate of in-stent restenosis (50%) at the 6-month follow-up examination. This was detected at transcranial color-coded duplex US (M.B. or M.S.) or, in case of insufficient insonation quality because of shadowing from the stent, at intraarterial angiography (R.d.M.d.R. and J.B. by consensus). The percentage of in-stent restenosis was measured at angiography as described previously.

Statistical Analysis
The degree (percentage) of stenosis was compared before and after stent placement by using the two-sample paired Wilcoxon signed rank test. was two-tailed, and its value was determined at = .05. A power analysis with the following assumptions was performed: = .05, P .05, a sample size of 18 stenoses, and a 90% probability of reduction of the stenosis with a stent. With these assumptions, the resulting power (1 - ß) is 96%.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Technical Success
The success rate in reaching the target lesion and placing the stent was 90% (18 of 20 stenoses). By using undersized stents, the degree of stenosis was reduced from a median of 82% (range, 72%–97%) to a median of 16% (range, 5%–40%; P < .001) (Fig 1). Because of tortuous vessel anatomy in the carotid siphon, we failed to access two lesions, one in the distal segment of the internal carotid artery and the other in the M1 segment of the middle cerebral artery; this resulted in a technical failure rate of 10%. These patients received only balloon angioplasty without stent placement, with a residual stenosis of 60% in one patient and 50% in the other. Eighteen lesions in 16 patients were treated with stents (16 INX stents and two S670 stents). A transfemoral approach was used in 13 of 16 patients, and a transbrachial approach was used in the remaining patients.

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Graph shows percentage of intracranial stenosis in 18 treated lesions before and after stent placement and at 6-month follow-up evaluation. The reduction of stenosis immediately after stent placement is significant (P < .001).

Vascular outcome.—On the immediate postprocedural angiograms, no dissections compromising blood flow, ruptures, vasospasms, or thromboembolic events were observed. In three lesions, there was a lack of apposition between the poststenotic dilated vessel and the distal stent struts. In two patients, we observed small dissections that did not compromise the blood flow. In one patient, the stent dislodged from the targeted lesion in the intracranial segment of the vertebral artery during the procedure, and we failed to recover the stent. It was eventually expanded in the middle part of the basilar artery without clinical complications.

Efficacy: Clinical and Vascular Outcome
Clinical outcome.—Of the 16 patients in whom intracranial stent placement was technically successful, none was lost to follow-up. None of the patients had developed any new ischemic neurologic deficit in the treated vascular territory at follow-up clinical examination at 6 months. The median follow-up period was 12 months (range, 6–24 months) and all patients remained asymptomatic. One patient died from a nonneurologic, non–procedure-related disease (intoxication), and the patient with reperfusion hemorrhage experienced a focal seizure. Therefore, the stroke rate for the entire follow-up period in the treated vascular territory was 6% (one of 16).

Vascular outcome.—Transcranial color-coded duplex US was performed at follow-up examinations. All treated vessels revealed laminar flow signal, and there was no evidence of more than 50% in-stent restenosis. In seven patients, the treated vessel could not be properly examined at US; therefore, according to our protocol, angiography was performed after 6 months. There was narrowing in the stent in all cases, and restenosis ranged from 18% to 48% luminal narrowing (Figs 1, 2).

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Digital subtraction angiograms of basilar artery stenosis. Posteroanterior (A) and lateral (B) images before stent placement show high-grade concentric stenosis in middle of basilar artery (arrow). Posteroanterior (C) and lateral (D) images immediately after stent placement show sufficient luminal increase, with small dissection (arrow) at distal end of stent. Stent covers origin of anterior inferior cerebellar artery (arrowhead), which remains patent. Posteroanterior (E) and lateral (F) images at 6-month follow-up show luminal narrowing in stent (arrow) but no high-grade stenosis or dissection. Anterior inferior cerebellar artery (arrowhead) is still patent.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

The risk and effectiveness of the procedure has to be balanced against the course of the disease with medical treatment. Unfortunately, data on the natural history of high-grade intracranial stenoses are limited (14,17). In our study, we selected patients with severe intracranial stenoses and recurrent symptoms, including transient ischemic attacks or minor strokes, while undergoing combined antithrombotic treatment. There is evidence that this selected group has a high risk of further strokes while undergoing medical treatment alone (3). We observed no transient ischemic attacks or strokes during the 6 months of follow-up. All patients remained neurologically stable and developed no new neurologic deficits. Despite the use of undersized stents and small areas with a lack of apposition of the stent struts in three cases, no high-grade or symptomatic restenoses were observed and no reinterventions were necessary. Thus, stent placement for intracranial stenosis seems to be effective in the short- and medium-term prevention of stroke.

This study had several shortcomings and limitations. The number of patients was small, and further data have to be collected before the risk of the procedure can be estimated. We observed no immediate complications, but, according to published data, we have to assume a remaining risk of thromboembolism, dissection, and rupture of the vessel. Procedural morbidity also depends on the skill and experience of the interventionalist; thus, intracranial stent placement should be limited to institutions with experienced staff.

The best medical treatment for patients with atherosclerotic intracranial stenosis, as well as the optimal periinterventional medical treatment, is unknown (2,14). Further trials have to be performed to compare different antithrombotic regimens. In our case series, no thromboembolic event occurred during the procedure, so we regard the regimen of acetylsalicylic acid, clopidogrel, and heparin as a sufficient periprocedural medication regimen. Other interventionalists have used platelet glycoprotein IIb/IIIa receptor inhibitors and heparin during the procedure, with similar results (13).

Further long-term follow-up data are necessary to confirm the positive initial results. The follow-up angiograms showed a narrowing in the stent in all patients, but no high-grade stenosis. It must be determined whether narrowing progresses over time or stops after layering of the stent with a neointima. In addition, the influence of stent placement on the long-term clinical outcome remains unknown.

We want to emphasize that intracranial stent placement cannot currently be recommended in every case of intracranial stenosis; in particular, it is not recommended in cases of asymptomatic stenosis. However, in selected patients with recurrent ischemic events due to high-grade intracranial stenosis, placement of undersized stents holds promise as an effective and safe procedure for the prevention of stroke.

	FOOTNOTES

 
Author contributions: Guarantors of integrity of entire study, R.d.M.d.R., J.B., M.S.; study concepts and design, R.d.M.d.R., J.B., M.S.; literature research, R.d.M.d.R.; clinical studies, M.B., M.S.; data acquisition, all authors; data analysis/interpretation, R.d.M.d.R., J.B., M.S.; manuscript preparation and editing, R.d.M.d.R., J.B., M.S.; manuscript definition of intellectual content, R.d.M.d.R., J.B.; manuscript revision/review, R.d.M.d.R., F.E.Z., M.S.; manuscript final version approval, all authors

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 

1. Sacco RL, Kargman DE, Gu Q, Zamanillo MC. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction: the Northern Manhattan Stroke Study. Stroke 1995; 26:14-20.[Abstract/Free Full Text]
2. Chimowitz MI. Angioplasty or stenting is not appropriate as first-line treatment of intracranial stenosis. Arch Neurol 2001; 58:1690-1692.[Free Full Text]
3. Thijs VN, Albers GW. Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 2000; 55:490-497.[Abstract/Free Full Text]
4. The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial. N Engl J Med 1985; 313:1191-1200.[Abstract]
5. Sundt TM, Jr, Smith HC, Campbell JK, Vlietstra RE, Cucchiara RF, Stanson AW. Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc 1980; 55:673-680.[Medline]
6. Takis C, Kwan ES, Pessin MS, Jacobs DH, Caplan LR. Intracranial angioplasty: experience and complications. AJNR Am J Neuroradiol 1997; 18:1661-1668.[Abstract]
7. Connors JJ, 3rd, Wojak JC. Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg 1999; 91:415-423.[Medline]
8. Marks MP, Marcellus M, Norbash AM, Steinberg GK, Tong D, Albers GW. Outcome of angioplasty for atherosclerotic intracranial stenosis. Stroke 1999; 30:065-1069.
9. Gomez CR, Misra VK, Campbell MS, Soto RD. Elective stenting of symptomatic middle cerebral artery stenosis. AJNR Am J Neuroradiol 2000; 21:971-973.[Abstract/Free Full Text]
10. Mori T, Kazita K, Chokyu K, Mima T, Mori K. Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol 2000; 21:249-254.[Abstract/Free Full Text]
11. Gomez CR, Misra VK, Liu MW, Wadlington VR, Terry JB, Tulyapronchote R. Elective stenting of symptomatic basilar artery stenosis. Stroke 2000; 31:95-99.[Abstract/Free Full Text]
12. Levy EI, Horowitz MB, Koebbe CJ, et al. Transluminal stent-assisted angioplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results. Neurosurgery 2001; 48:1215-1221.[CrossRef][Medline]
13. Lylyk P, Cohen JE, Ceratto R, Ferrario A, Miranda C. Angioplasty and stent placement in intracranial atherosclerotic stenoses and dissections. AJNR Am J Neuroradiol 2002; 23:430-436.[Abstract/Free Full Text]
14. Chimowitz MI, Kokkinos J, Strong J, et al. The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995; 45:1488-1493.[Abstract/Free Full Text]
15. Baumgartner RW, Mattle HP, Schroth G. Assessment of 50% and <50% intracranial stenoses by transcranial color-coded duplex sonography. Stroke 1999; 30:87-92.[Abstract/Free Full Text]
16. McCabe DJ, Brown MM, Clifton A. Fatal cerebral reperfusion hemorrhage after carotid stenting. Stroke 1999; 30:2483-2486.[Abstract/Free Full Text]
17. Akins PT, Pilgram TK, Cross DT, 3rd, Moran CJ. Natural history of stenosis from intracranial atherosclerosis by serial angiography. Stroke 1998; 29:433-438.[Abstract/Free Full Text]

This article has been cited by other articles:

				D.C. Suh, J.K. Kim, J.W. Choi, B.S. Choi, H.W. Pyun, Y.J. Choi, M.-H. Kim, H.R. Yang, H.I. Ha, S.J. Kim, et al. Intracranial Stenting of Severe Symptomatic Intracranial Stenosis: Results of 100 Consecutive Patients AJNR Am. J. Neuroradiol., April 1, 2008; 29(4): 781 - 785. [Abstract] [Full Text] [PDF]

				W.-J. Jiang, X.-T. Xu, M. Jin, B. Du, K.-H. Dong, and J.-P. Dai Apollo Stent for Symptomatic Atherosclerotic Intracranial Stenosis: Study Results AJNR Am. J. Neuroradiol., May 1, 2007; 28(5): 830 - 834. [Abstract] [Full Text] [PDF]

				W.-J. Jiang, B. Du, T. W. Leung, X.-T. Xu, M. Jin, and K.-H. Dong Symptomatic Intracranial Stenosis: Cerebrovascular Complications from Elective Stent Placement Radiology, April 1, 2007; 243(1): 188 - 197. [Abstract] [Full Text] [PDF]

				W. J. Jiang, X. T. Xu, B. Du, K. H. Dong, M. Jin, Q. H. Wang, and N. Ma Comparison of elective stenting of severe vs moderate intracranial atherosclerotic stenosis Neurology, February 6, 2007; 68(6): 420 - 426. [Abstract] [Full Text] [PDF]

				S. Heye, G. Maleux, J. Van Loon, and G. Wilms Symptomatic Stenosis of the Cavernous Portion of the Internal Carotid Artery due to an Irresectable Medial Sphenoid Wing Meningioma: Treatment By Endovascular Stent Placement AJNR Am. J. Neuroradiol., August 1, 2006; 27(7): 1532 - 1534. [Abstract] [Full Text] [PDF]

				R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, 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. Circulation, March 14, 2006; 113(10): e409 - e449. [Abstract] [Full Text] [PDF]

				R. du Mesnil de Rochemont, B. Yan, F.E. Zanella, D.A. Rufenacht, and J. Berkefeld Conformability of balloon-expandable stents to the carotid siphon: an in vitro study. AJNR Am. J. Neuroradiol., February 1, 2006; 27(2): 324 - 326. [Abstract] [Full Text] [PDF]

				R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, 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, February 1, 2006; 37(2): 577 - 617. [Abstract] [Full Text] [PDF]

				S. E. Kasner, M. I. Chimowitz, M. J. Lynn, H. Howlett-Smith, B. J. Stern, V. S. Hertzberg, M. R. Frankel, S. R. Levine, S. Chaturvedi, C. G. Benesch, et al. Predictors of Ischemic Stroke in the Territory of a Symptomatic Intracranial Arterial Stenosis Circulation, January 31, 2006; 113(4): 555 - 563. [Abstract] [Full Text] [PDF]

				W. Yoon, J. J. Seo, K. H. Cho, M. K. Kim, B. C. Kim, M. S. Park, T. S. Kim, J. K. Kim, and H. K. Kang Symptomatic Middle Cerebral Artery Stenosis Treated with Intracranial Angioplasty: Experience in 32 Patients Radiology, November 1, 2005; 237(2): 620 - 626. [Abstract] [Full Text] [PDF]

				I. M. Kessler, C. Mounayer, M. Piotin, L. Spelle, J. R. Vanzin, and J. Moret The Use of Balloon-Expandable Stents in the Management of Intracranial Arterial Diseases: A 5-Year Single-Center Experience AJNR Am. J. Neuroradiol., October 1, 2005; 26(9): 2342 - 2348. [Abstract] [Full Text] [PDF]

				R. Moftakhar, A. S. Turk, D. B. Niemann, S. Hussain, S. Rajpal, T. Cook, M. Geraghty, B. Aagaard-Kienitz, P. A. Turski, and G. C. Newman Effects of Carotid or Vertebrobasilar Stent Placement on Cerebral Perfusion and Cognition AJNR Am. J. Neuroradiol., August 1, 2005; 26(7): 1772 - 1780. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by du Mesnil de Rochemont, R. Articles by Berkefeld, J. Search for Related Content PubMed PubMed Citation Articles by du Mesnil de Rochemont, R. Articles by Berkefeld, J.