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Stenting in Intracranial Stenosis: Current Controversies and Future Directions
Arindam R Chatterjee1, Colin P Derdeyn
1Department of Radiology, Medical University of South Carolina, Suite 210, 96 Jonathan Lucas St., Charleston, SC, 29425, USA, rano.chatterjee@gmail.com.
Insights
Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) is a last resort. Medical management is superior for stroke prevention, though future studies are needed for selected patients.
Area of Science:
- Neurology
- Interventional Cardiology
Background:
- Intracranial atherosclerotic stenosis (ICAS) poses a significant stroke risk.
- Patients with high-grade stenosis unresponsive to medical therapy often face limited options.
Purpose of the Study:
- To evaluate the efficacy and safety of angioplasty and stenting versus medical management for ICAS.
- To identify potential benefits and risks associated with endovascular treatment for ICAS.
Main Methods:
- Review of current literature comparing angioplasty and stenting with medical therapy for ICAS.
- Analysis of stroke rates, procedural complications, and long-term outcomes.
Main Results:
- Medical management, including risk factor control and dual antiplatelet therapy, demonstrates superiority in preventing future strokes.
- Angioplasty and stenting carry unacceptably high procedural risks of hemorrhagic and ischemic stroke.
- Post-procedure stroke rates are comparable to those seen with medical treatment alone.
Conclusions:
- Angioplasty and stenting for ICAS is currently a last resort, with unclear benefits.
- Further research is needed to identify high-risk subgroups and refine interventional techniques.
- Selected patients with recurrent events despite aggressive medical management may still be considered, but benefits remain uncertain.
Abstract:
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.
