Stenting in Intracranial Stenosis: Current Controversies and Future Directions

Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) are a last resort for patients with high-grade intracranial stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.