Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video

Area of Science:

• Neurology
• Interventional Neuroradiology
• Vascular Neurology

Background:

• Intracranial atherosclerotic disease (ICAD) is a significant cause of stroke.
• Optimal medical therapy, including antiplatelet agents, is the primary treatment for symptomatic ICAD.
• Endovascular interventions like angioplasty and stenting are reserved for recurrent ischemic events refractory to medical management.

Purpose of the Study:

• To demonstrate the technique, indications, and vessel/stent sizing for intracranial angioplasty and stenting.
• To illustrate the management of a complex case of recurrent M2 middle cerebral artery occlusion.

Main Methods:

• A patient with persistent left M2 middle cerebral artery occlusion despite mechanical thrombectomy and optimized medical therapy underwent intracranial angioplasty and stenting.
• Submaximal angioplasty was performed using a J-configured microwire to mitigate perforation risk.
• A balloon-mounted intracranial stent was deployed to address high-grade stenosis and restore perfusion.

Main Results:

• The procedure successfully restored perfusion, as evidenced by the resolution of the perfusion deficit on postoperative computed tomography.
• The patient achieved therapeutic P2Y12 levels prior to the intervention.
• The use of a specific microwire facilitated safe navigation across the lesion.

Conclusions:

• Intracranial angioplasty and stenting can be an effective treatment for recurrent intracranial stenosis causing stroke.
• Careful technique, including appropriate microwire selection and angioplasty, is crucial for successful outcomes.
• This case highlights the utility of endovascular intervention when medical therapy fails to prevent recurrent ischemic events.