[Intravascular technics of cerebral revascularization]

Abstract

Two techniques of cerebral revascularization have been developed: angioplasty of the brachiocephalic vessels (204 cases) and local intra-arterial fibrinolysis in the carotid region (26 cases). Angioplasty appears to be the treatment of choice for inflammatory and atherosclerotic stenoses of the main trunks arising from the aortic arch (82 cases). Stenoses of the origin of the vertebral artery are not often ulcerated and may also be treated by angioplasty (42 cases) as long as the stenosis has been recognized as the cause of vertebral insufficiency symptoms. Among the stenoses of the carotid bifurcation, recurrent postsurgical ones are rather easily treated by angioplasty, particularly when they are recognized early by Doppler examination. Postsurgical and inflammatory stenoses do not require cerebral protection during angioplasty. Conversely, cerebral protection is mandatory for treatment of atherosclerotic stenoses because of the risk of embolic detachment of particles in to brain circulation. A new triple coaxial catheter system has been designed which seems so far to be very efficient. Local intra-arterial fibrinolysis in the carotid region is selected on the basis of clinical signs, the delay after onset and results of CT and complete cerebral angiographic workup. A classification into three topographic groups is proposed. The group at highest risk of post-fibrinolysis hemorrhage is the one with occlusion of the lenticulostriate arteries. It would seem hazardous to undertake fibrinolysis in a patient of this group unless it can be started no later than 4 or 5 hours after clinical onset. Rapid transportation of stroke patients is recommended so that CT and complete arteriography may be performed before deciding whether to use fibrinolytics.