title: Wingspan experience at Beijing Tiantan Hospital: new insights into the mechanisms of procedural complication from viewing intraoperative transient ischemic attacks during awake stenting for vertebrobasilar stenosis.
abstract: OBJECTIVE
  Intracranial vertebrobasilar artery (VBA) stenosis portends a stroke and death rate of 8.5-22.8% annually despite medical therapy. Stenting has emerged as a treatment option but also carries substantial risk. Awake stenting under local anesthesia to minimize major procedural complication was investigated.
  
  
  METHODS
  Between January 2007 and December 2008, 43 of 46 consecutive patients with severe symptomatic intracranial VBA stenosis underwent elective angioplasty assisted with self-expanding Wingspan stent under local anesthesia at our institute. All data were collected prospectively.
  
  
  RESULTS
  All 43 patients tolerated the stenting procedure under local anesthesia well. Forty-two patients (97.7%) were stented successfully. Within 30 days, there were three periprocedural strokes, including thromboembolic infarct, pontine perforator infarct and intracranial hemorrhage, without fatality. In addition, five patients had intraoperative brainstem transient ischemic attacks (TIAs) seconds after the deployment of the stent delivery system across the tortuous VBA. The symptoms and signs included impaired consciousness (n=5), dysarthria (n=3), convulsion (n=2), conjugate horizontal gaze palsy (n=2), nystagmus (n=2) and pinpoint pupils (n=1). There was angiographic evidence of VBA straightening without thromboembolism. The TIAs resolved within minutes of prompt removal of the delivery catheter.
  
  
  CONCLUSIONS
  VBA stenting under local anesthesia is feasible with a 7% periprocedural stroke risk. Awake stenting allows timely detection of intraoperative TIAs. The mechanism of intraoperative TIA appears to be stent delivery system induced VBA straightening and distortion of its vascular tree. A devastating stroke may ensue if the TIA is not detected and distortion of VBA perforators is not reversed promptly.
authors: Department of Interventional Neuroradiology, Beijing Tiantan Hospital, The Capital Medical University, Beijing, China. cjr.jiangweijian@vip.163.com
authors: W-J
authors: WJ
authors: Jiang
authors: W
authors: W
authors: Yu
authors: B
authors: B
authors: Du
authors: E H C
authors: EH
authors: Wong
authors: F
authors: F
authors: Gao
mesh_terms: D000368:Aged; D000772:Anesthesia, Local / Q000009:adverse effects; D002681:China / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000639:trends; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000209:etiology; D002546:Ischemic Attack, Transient / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D015607:Stents / Q000009:adverse effects; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000453:epidemiology / Q000601:surgery*; D014851:Wakefulness