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Reply: B. Aagaard-Kienitz b and H.A. Rowley b b University of Wisconsin Madison, Wis D. Fiorella c c Cleveland Clinic Foundation Cleveland, Ohio We thank Dr Gröschel and colleagues for their interest in our work and we appreciate their comments. We agree that patients with intracranial stents require close follow-up, preferably with noninvasive imaging. However, given the sparse data available, a strong recommendation for any specific imaging technique is limited. The purpose of our article was not to advocate any specific imaging study for follow-up of patients with stents but rather to highlight a potential pitfall with CT angiography (CTA) that we have observed. We believe that CTA is the best choice available in most institutions for several reasons: CTA is widely available at all hospitals able to perform intracranial stent placement. CTA is readily available and easy to interpret by most physicians. CTA data can be postprocessed to evaluate vessels in multiple projections and with different reconstruction algorithms. Physiologic data from perfusion imaging can be performed concurrently, allowing further understanding of the hemodynamic consequences of the stent. Transcranial duplex sonography (TCD) is potentially a viable alternative; however, most institutions do not have wide access to high-quality TCD. TCD has the same or greater limitations as standard sonography in that it is very operator-dependent and potentially limited by the presence or absence of acoustic windows. There are also pitfalls in evaluating TCD data. In the setting of in-stent restenosis (ISR), TCD velocities are usually increased. However, as in the present case, they can be blunted or decreased, and in other cases, they can be normal or unable to be insonated. As such, almost regardless of the TCD data—high, low, blunted, normal, etc—if there is clinical suggestion of ISR, a confirmatory study such as a CTA or angiography is almost always required to dictate patient management. Although advocating TCD for the diagnosis of ISR, the authors do not present any data to demonstrate the sensitivity or specificity of the test. In fact, in the case presented, the TCD findings were somewhat confusing and required additional testing to understand. As such, we advocate noninvasive imaging to screen patients with intracranial stents, but conventional digital subtraction angiography is required in any patient with suggested restenosis on clinical findings or noninvasive imaging. This Article Full Text (PDF) All Versions of this Article: ajnr.A1207v1 ajnr.A1207v2 29/8/e66 most recent Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Turk, A.S. Articles by Fiorella, D. Search for Related Content PubMed Articles by Turk, A.S. Articles by Fiorella, D. Hotlight (NEW!) What's Hotlight? Home Subscribe Author Instructions Submit Online Search the AJNR Archives Feedback Help Copyright © 2010 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

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Publisher
American Journal of Neuroradiology
Copyright
Copyright © 2010 by the American Society of Neuroradiology.
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.A1207
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Abstract

B. Aagaard-Kienitz b and H.A. Rowley b b University of Wisconsin Madison, Wis D. Fiorella c c Cleveland Clinic Foundation Cleveland, Ohio We thank Dr Gröschel and colleagues for their interest in our work and we appreciate their comments. We agree that patients with intracranial stents require close follow-up, preferably with noninvasive imaging. However, given the sparse data available, a strong recommendation for any specific imaging technique is limited. The purpose of our article was not to advocate any specific imaging study for follow-up of patients with stents but rather to highlight a potential pitfall with CT angiography (CTA) that we have observed. We believe that CTA is the best choice available in most institutions for several reasons: CTA is widely available at all hospitals able to perform intracranial stent placement. CTA is readily available and easy to interpret by most physicians. CTA data can be postprocessed to evaluate vessels in multiple projections and with different reconstruction algorithms. Physiologic data from perfusion imaging can be performed concurrently, allowing further understanding of the hemodynamic consequences of the stent. Transcranial duplex sonography (TCD) is potentially a viable alternative; however, most institutions do not have wide access to high-quality TCD. TCD has the same or greater limitations as standard sonography in that it is very operator-dependent and potentially limited by the presence or absence of acoustic windows. There are also pitfalls in evaluating TCD data. In the setting of in-stent restenosis (ISR), TCD velocities are usually increased. However, as in the present case, they can be blunted or decreased, and in other cases, they can be normal or unable to be insonated. As such, almost regardless of the TCD data—high, low, blunted, normal, etc—if there is clinical suggestion of ISR, a confirmatory study such as a CTA or angiography is almost always required to dictate patient management. Although advocating TCD for the diagnosis of ISR, the authors do not present any data to demonstrate the sensitivity or specificity of the test. In fact, in the case presented, the TCD findings were somewhat confusing and required additional testing to understand. As such, we advocate noninvasive imaging to screen patients with intracranial stents, but conventional digital subtraction angiography is required in any patient with suggested restenosis on clinical findings or noninvasive imaging. This Article Full Text (PDF) All Versions of this Article: ajnr.A1207v1 ajnr.A1207v2 29/8/e66 most recent Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Turk, A.S. Articles by Fiorella, D. Search for Related Content PubMed Articles by Turk, A.S. Articles by Fiorella, D. Hotlight (NEW!) What's Hotlight? Home Subscribe Author Instructions Submit Online Search the AJNR Archives Feedback Help Copyright © 2010 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X

Journal

American Journal of Neuroradiology – American Journal of Neuroradiology

Published: Sep 1, 2008

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