Patients
This study was approved by the ethics committee of our hospital, and all patients provided written informed consent. We retrospectively reviewed patients from January to August 2019 at our institution. All patients were diagnosed with imaging studies including computed tomography angiography (CTA), magnetic resonance angiography (MRA), and/or DSA. Patients with concomitant UIA and cerebral vascular stenosis were included. Patients demographics, clinical information, procedure details, complications and clinical follow-up results were collected. Patients were excluded from the study if there was no complete information. Patients who were lost to follow-up or without further treatment after diagnosis were eliminated in further analyses. Patients were divided into 4 groups according to lesions that was treated (UIA, stenosis, both lesions in a single session or both lesions in separated sessions). Patients were divided into another 2 groups based on the relationship between the UIA and stenosis (ipsilateral and non-ipsilateral). The demographics, complications and clinical outcomes were compared among groups.
Definitions of variables
Patients’ demographics and clinical data were collected. In the current study, cerebral vascular include intracranial vascular, as well as extracranial segment of common carotid artery (CCA), internal carotid artery (ICA) and vertebral artery (VA). Initial clinical presentations were categorized into specific ischemic symptoms and non-specific symptoms. Specific ischemic symptoms are symptoms directly resulted by relative stenosis, include stenosis related numbness of anybody parts, weakness of limbs, vertigo and slurred speech, etc. Some patients found UIA incidentally when performing routine medical examination (asymptomatic UIA). Non-specific symptoms include non-specific headache, dizziness and asymptomatic UIA. The stenosis was stratified into 4 distinct categories (NASCET criteria) based on degree: mild (< 50%), moderate (50%-70%), severe (70%-99%) and occluded (100%).
The relationship between UIA and stenosis is categorized into two types according to the location: ipsilateral and non-ipsilateral. The former refers to both UIA and stenosis located at left CCA system (left CCA, Left ICA, Left MCA and Left ACA), right CCA system (right CCA, right ICA, right MCA and right ACA) or posterior circulation (Unless UIA and stenosis located at bilateral VAs respectively). For multiple UIAs and/or stenosis, any two lesions located at the same system were categorized into ipsilateral group.
Endovascular embolization status of the UIA was classified into complete occlusion, near complete occlusion and partial occlusion according to Raymond Classification for intracranial embolization. Pipeline is excepted because flow diverter is not applicable for Raymond classification.
Periprocedural complications are categorized into ischemic and hemorrhagic types. Ischemic complication is defined as any additional neurologic deficits compared with pre-operation and infarctions confirmed by CT/MRI within 30 days after procedure[11]. Hemorrhagic complication is defined as intracranial hemorrhage (ICH/SAH) happened within 7 days after procedure confirmed by CT[12]. All patients were evaluated with the modified Rankin Scale (mRS) before procedure and at last follow-up. mRS 0–2 (independent) is regarded as favorable clinical outcome and mRS ≥ 3 (dependent) is regarded as unfavorable clinical outcome.
UIA embolization and Stenosis angioplasty
There is no consensus for the treatment of concomitant aneurysm and stenosis. Treatment indication for stenosis and UIA is strictly according to the Guidelines from the American Heart Association/American Stroke Association(AHA/ASA) respectively[13, 14]. Dual antiplatelet therapy that comprised aspirin (100 mg/day) and clopidogrel (75 mg/day) was initiated at least 5 days before stent implantation. For UIA embolization, all procedures were performed under general anesthesia. A 6- to 8-F sheath was inserted through the femoral artery and a 6- to 8-F guiding catheter was navigated into the internal carotid or the vertebral artery. For ostial ICA, an 8-F guiding catheter was used for all patients. The guiding catheter was flushed via a pressure bag with saline containing 3000U of heparin/500 ml. The microcatheter tip was guided to the desired position using micro-guidewire. The UIA was embolized with coils alone, stent-assisted coils or pipeline with or without coils. For angioplasty, general anesthesia and local anesthesia are adopted for intracranial and extracranial lesions respectively. During the intervention, 3000–4000 IU of heparin was administered, and additional 1000 IU per hour. Angioplasty (balloon angioplasty along or stenting) was done according to the standardized routine form AHA/ASA and our Unit[14]. Before and immediately after the procedure, the neurological function of every patient was evaluated.
Follow-up
All patients received in-person or telephone follow-up. The final mRS score was based on their functional status at last follow-up.
Statistical analyses
Patients’ characteristics were described with frequencies for categorical variables and mean standard deviation for continuous variables. Categorical variables were compared using Fisher exact test or the Pearson χ2 test. Continuous variables were compared between groups using student’s t test or one-way ANOVA. All P values were reported as 2-sided. P < 0.05 was considered significant. All statistical analyses were conducted by using SPSS 22.0 (Chicago, IL, USA).