Elsevier

The Lancet

Volume 363, Issue 9411, 6 March 2004, Pages 804-813
The Lancet

Review
Endovascular treatment of cerebrovascular diseases and intracranial neoplasms

https://doi.org/10.1016/S0140-6736(04)15697-3Get rights and content

Summary

Cerebrovascular diseases are an important cause of morbidity and mortality worldwide. Endovascular treatment has emerged as a minimally invasive approach to treat cerebrovascular diseases and possibly intracranial neoplasms. Practice patterns for selection of patients for endovascular treatment are continuously being modified on the basis of new information derived from clinical studies. In this review, I discuss the various endovascular treatments for diseases such as ischaemic stroke, carotid and intracranial stenosis, intracranial aneurysms, arteriovenous malformations, malignant gliomas, and meningiomas.

Introduction

Cerebrovascular diseases are a major global health problem, result in high morbidity and mortality, and are the leading cause of disability.1 Over the past few years, developments in endovascular treatments for cerebrovascular diseases have expanded the horizon of treatment by use of minimally invasive techniques. In endovascular treatment, drugs and devices are introduced through catheters or microcatheters placed into blood vessels through the skin. The initial work of Haschek, Lindenthal, and Moniz2 led to development of cerebral angiography as a diagnostic method. In the early 1960s, Luessenhop and Velasquez3 showed that intracranial vessels could be catheterised with flow-directed balloon tipped catheters, and in 1974, Serbinenko4 reported use of balloon tipped micro-catheters and detachable balloons for treatment of intracranial aneurysms—starting the use of endovascular procedures as a method of treatment.

The basic principle of all endovascular procedures involves percutaneous entry into the femoral, radial, or brachial artery5, 6 by use of a modification of Seldinger's technique.7 Guide catheters or sheaths are introduced through the aorta into the supra-aortic vessel of interest. Microcatheters, balloon catheters, and stent delivery devices are introduced through the guide catheter and guided to the target lesion with flexible microwires. Advanced designs of microcatheters including flow directed and magnetically guided microcatheters8 have allowed highly selective delivery of coils, embolic materials, and drugs into regions of interest.

Section snippets

Acute ischaemic stroke

In 1958, Sussmann and Fitch9 reported successful recanalisation of an acutely occluded internal carotid artery after intra-arterial injection of plasmin. Subsequent attempts at intra-arterial administration of thrombolytics were unsuccessful because the time window for intervention was not clearly understood and doctors had little experience in guiding catheters into the intracranial vessels. With better understanding of the time window, randomised trials10, 11 showed the benefit of using

Carotid stenosis

Randomised trials have shown the benefit of carotid endarterectomy in reducing the risk of stroke in patients with moderate to severe symptomatic (⩾50%)34, 35, 36 or asymptomatic (⩾60%)37 carotid artery stenosis. However, in general practice, perioperative complications are sometimes high enough that potential benefits are obscured when carotid endarterectomy is done on patients with unfavourable clinical and anatomical characteristics.38, 39, 40, 41, 42 Carotid angioplasty with stent placement

Intracranial stenosis

Intracranial stenosis is responsible for 8–10% of all ischaemic strokes.81, 82 The yearly rate of recurrent stroke in patients with intracranial stenosis is about 8–12%83, 84 and for those who do not respond to antithrombotic treatment, the rate of recurrent ischaemic events can be as high as 52%.85 Patients with symptomatic vertebrobas-ilar stenosis have a low stroke-free survival rate of 76% at 12months and 48% at 5years.82 Percutaneous translumi-nal angioplasty with possible stent placement

Intracranial aneurysms

Intracranial aneurysms are an important health problem worldwide, affecting about 2% of the population.90 In 1941, Werner and colleagues91 inserted silver wires into an intracranial aneurysm by use of a transorbital approach to prevent rupture by protecting the susceptible wall of the aneurysm from the stress of pulsatile blood. Subsequently, placement of iron particles, detachable balloons, and pushable platinum coils was attempted.2 In the late 1980s, soft platinum coil soldered to a

Arteriovenous malformations

In 1930, Brooks117 reported closure of carotid-cavernous fistula with surgical introduction of muscle embolus in the carotid artery. Lussenhop and colleagues118 subsequently reported embolisation with silastic spheres and silk sutures introduced into the internal carotid artery to treat cerebral arteriovenous malformation. Technical advances such as flow directed and other specialised microcatheters and new embolic agents have increased the therapeutic potential of embolisation for cerebral

Intracranial tumours

Intra-arterial delivery of chemotherapeutic agents into the vascular bed of intracranial tumours has been suggested to achieve a high concentration in selected regions of the brain.129 A phase III trial130 showed no difference in survival between the 153 patients with newly resected malignant glioma who were randomly allocated to intracarotid injection of carmustine and the 126 who received this compound intravenously. Serious toxic effects in the intra-arterial group, consisting of

Future applications

The safety and efficacy of endovascular procedures for cerebrovascular diseases is expected to improve with new technology. New applications such as intra-arterial delivery of stem cells derived from bone marrow to damaged regions of the brain have shown promise in experimental models.139 These cells can be deposited in the regions of injured brain, survive, and express proteins similar to neurons. The intra-arterial route has also been proposed as a method for delivering plasmid DNA

Search strategy and selection criteria

I based my review on personal knowledge of the subject supplemented by data derived from multi-centre randomised trials, non-randomised controlled studies with independent outcome ascertainment, and selected observational studies. The information was identified with multiple searches on MEDLINE from 1985 to the present by cross referencing key words of cerebrovascular disease, stroke, intracranial neoplasms, or clinical trials, with intra-arterial thrombolysis, angioplasty, stent, embolisation,

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