New technique shows promise in preventing recurrent stroke

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The surgical procedure, Encephaloduroarteriosynangiosis (EDAS) dramatically reduced the rate of recurrent strokes among patients with atherosclerotic disease, a Phase II clinical trial showed.

Atherosclerotic disease, also known as hardening of the arteries, is a build-up of plaque that narrows the arteries leading to the brain. The condition is known to increase patients' risk of having a series of strokes.

Exciting new results from a Phase II clinical trial conducted by vascular neurosurgeons at Cedars-Sinai demonstrated that a new procedure reduced recurrent stroke rates from 37% to 10.7%.

Encephaloduroarteriosynangiosis (EDAS) is a new procedure that was used.

“The EDAS procedure is unique in that it involves rerouting arteries from the scalp and membranes that cover the brain, to segments of the brain at risk of stroke,” said Dr Nestor Gonzalez, director of the Cedars-Sinai Neurovascular Laboratory. “Similar to gardening, over time, new blood vessels form and create a fresh path for blood oxygen to reach the brain.”

This gardening-like surgical technique differs from current, conventional approaches to reduce recurrent stroke, which include intensive medical management and various procedures, ranging from angioplasty and stenting to direct bypass surgery.

“Your brain needs a steady supply of oxygen-rich blood in order to function properly,” said Dr Keith Black, professor and chair of the department of neurosurgery. “This work is an important step in increasing the vital vessels in the brain and ensuring that patients with this complex condition have an innovative and minimally invasive option for care.”

The Neurovascular Centre and department of neurosurgery at Cedars-Sinai provide personalised care for aneurysms, strokes and other neurovascular problems, using state-of-the-art imaging technology, a dedicated intensive care unit, advanced therapies and new surgical techniques.

As a next step, Gonzalez and his team are working with the National Institutes of Health – a funder of this work – to launch a large, multicentre Phase III clinical trial at medical centres across the nation. These sites will allow willing patients with atherosclerotic disease to participate in clinical research.

“Clinical research is a critical component and a necessary step to advance the science and treatments available to patients with this unique yet common condition,” said Gonzalez. “As the trial expands from Los Angeles to other parts of the country, I hope patients consider participating in the study of this promising technique.”

Funding: This research was supported by the National Institute of Neurological Disorders and Stroke of the NIH.

 

Study details
Encephaloduroarteriosynangiosis Averts Stroke in Atherosclerotic Patients With Border-Zone Infarct: Post Hoc Analysis From a Performance Criterion Phase II Trial

Miguel D Quintero-Consuegra, Juan F Toscano, Robin Babadjouni, Peyton Nisson, Mohammad N Kayyali, Daniel Chang, Eyad Almallouhi, Jeffrey L Saver, Nestor R Gonzalez

Published in Neurosurgery on 19 February 2021

Abstract
Background
Intracranial atherosclerotic disease (ICAD) is one of the leading causes of stroke worldwide. Patients with ICAD who initially present with ischemia in border-zone areas and undergo intensive medical management (IMM) have the highest recurrence rates (37% at 1 yr) because of association with hemodynamic failure and poor collaterals.
Objective
To evaluate the effect of encephaloduroarteriosynagiosis (EDAS) on stroke recurrence in patients with ICAD and border-zone stroke (BDZS) at presentation.
Methods
A phase II clinical trial of EDAS revascularization for symptomatic ICAD failing medical management (EDAS Revascularization for Symptomatic Intracranial Atherosclerosis Steno-occlusive [ERSIAS]) was recently concluded. We analyze the outcomes of the subgroup of patients with BDZS at presentation treated with EDAS vs the previously reported Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) IMM subgroup with BDZS at presentation.
Results
Of 52 patients included in the ERSIAS trial, 35 presented with strokes at baseline, and 28 had a BDZ pattern, including 15 (54%) with exclusive BDZS and 13 (46%) with mixed patterns (BDZ plus other distribution). Three of the 28 (10.7%) had recurrent strokes up to a median follow-up of 24 months. The rate of recurrent stroke in ICAD patients with BDZS at presentation after EDAS was significantly lower than the rate reported in the SAMMPRIS IMM subgroup with BDZS at presentation (10.7% vs 37% P = .004, 95% CI = 0.037-0.27).
Conclusions
ICAD patients with BDZS at presentation have lower rates of recurrent stroke after EDAS surgery than those reported with medical management in the SAMMPRIS trial. These results support further investigation of EDAS in a randomized clinical trial.

 

Cedars-Sinai Medical Centre material

 

Neurosurgery study (Open access)

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