Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video
Related Experiment Video
Updated: Nov 6, 2025
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Rimal H Dossani1,2, Muhammad Waqas1,2, Justin M Cappuzzo1,2
1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
Insights
Intracranial atherosclerotic disease (ICAD) can cause stroke. This case study details successful intracranial angioplasty and stenting for a patient with persistent M2 occlusion despite thrombectomy and medical therapy.
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.
Abstract:
Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.1,2 Submaximal angioplasty has also been described.3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.
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