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KEY FACTS
Terminology
Pre-Procedure
Procedure
Post-Procedure
Outcomes
TERMINOLOGY
Intracranial Stenosis Due to Atherosclerosis
Causes 8-10% of ischemic strokes in North America
Risk factors for intracranial stenosis
Hypertension
Race
Asian
Most common cause of stroke (33-56%)
Latino
African descent
Metabolic syndrome
Mechanisms of ischemic stroke due to intracranial stenosis
Thromboembolism distal to stenosis
In situ thrombosis at arterial stenosis
Hemodynamic hypoperfusion distal to stenosis
Perforating/branch artery occlusion by atheroma
Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study
Patients with prior TIA/nondisabling stroke from symptomatic intracranial stenosis of 50-99% severity
Randomized to warfarin or aspirin
Aspirin shown to be safer and as effective
15% stroke rate in stenotic territory over 1.8 years
44% of these strokes disabling
If stenosis ≥ 70%, stroke rate was 23%
Intracranial Stenosis Angioplasty/Stenting
Primary angioplasty (PTA) of symptomatic intracranial stenoseswithout stenting
Early studies reported high PTA-associated risks
Vessel rupture, vasospasm, dissection
Death in up to 33% of patients
Subsequently, several reports of successful PTA
Slower balloon inflation and balloon undersizing
Reduced complications
Occasionally suboptimal angiographic results
Cochrane review of 79 articles (total of 1,999 cases)
Included case series with ≥ 3 cases of 1° PTA
Overall perioperative stroke rate (7.9%)
Perioperative death rate (3.4%)
Perioperative stroke or death rate (9.5%)
1-year follow-up stroke rate (6%)
Technical disadvantages as opposed to stenting
Arterial dissection
Potential for increased thrombogenicity
Immediate elastic recoil
Higher re-stenosis rates
No trials comparing PTA vs. stenting
Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA trial)
Trial using Neurolink® (Guidant; San Francisco, CA) balloon expandable stent
Successful stent placement (95%)
30-day periprocedural stroke rate (6.6%)
6 months after stenting > 50% re-stenosis in 32% of intracranial stents
61% of recurrent stenoses were asymptomatic
Neurolink stent no longer manufactured
Wingspan study: Prospective multicenter trial
Successful stent placement (97.8%)
Self-expanding nitinol stent deployed after PTA
30-day periprocedural stroke/death rate (4.5%)
At 6-month angiographic follow-up
> 50% restenosis in 6.8%; all symptomatic
At 6-month clinical follow-up
Ipsilateral stroke/death rate (7.0%)
All strokes (9.7%)
All-cause mortality (2.3%)
FDA granted humanitarian device exemption (HDE)
Based upon results of Wingspan study
NIH Multicenter Wingspan Stent Registry
129 patients with 70–99% intracranial stenosis
Stenosis reduced to < 50% in 97% of patients
30-day stroke or death risk (9.6%)
Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS trial)
Compares safety/effectiveness of intensive medical therapy plus stenting vs. intensive medical therapy alone for intracranial stenosis
Entry criteria
Symptomatic intracranial stenosis ≥70%
TIA or stroke within 30 days
Both study arms receive dual antiplatelet therapy
Aspirin, clopidogrel for 3 months after enrolling
Intensive management of vascular risk factors
Blood pressure/cholesterol management
Enrollment stopped prematurely
Better outcomes with medical than stent group
30-day death/stroke rate: PTA/stenting (14%) vs. medical therapy (5.8%)
Trial will continue to follow enrolled subjects
PRE-PROCEDURE
Indications
Contraindications
Pre-Procedure Imaging
Getting Started
PROCEDURE
Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies
POST-PROCEDURE
Expected Outcome
Things to Do
OUTCOMES
Complications
Selected References
Al-Ali F et al: Predictors of unfavorable outcome in intracranial angioplasty and stenting in a single-center comparison: results from the borgess medical center-intracranial revascularization registry. AJNR Am J Neuroradiol. 32(7):1221-6, 2011
Li J et al: Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis. Cardiovasc Intervent Radiol. Epub ahead of print, 2011
Short JL et al: Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol. 1:160, 2011
Yu SC et al: Angioplasty and stenting of atherosclerotic middle cerebral arteries with wingspan: evaluation of clinical outcome, restenosis, and procedure outcome. AJNR Am J Neuroradiol. 32(4):753-8, 2011
Fields JD et al: Indications and applications of arterial stents for stroke prevention in atherosclerotic intracranial stenosis. Curr Cardiol Rep. 12(1):20-8, 2010
Lutsep HL: Symptomatic intracranial stenosis: best medical treatment vs. intracranial stenting. Curr Opin Neurol. 22(1):69-74, 2009
Schumacher HC et al: Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis. J Vasc Interv Radiol. 20(7 Suppl):S451-73, 2009
Bose A et al: A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 38(5):1531-7, 2007
Cruz-Flores S et al: Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev. 3:CD004133, 2006
Marks MP et al: Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke. 37(4):1016-20, 2006
Mazighi M et al: Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 66(8):1187-91, 2006
SSYLVIA Study Investigators: Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 35(6):1388-92, 2004
Connors JJ 3rd et al: Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg. 91(3):415-23, 1999
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Pre-Procedure
Procedure
Post-Procedure
Outcomes
TERMINOLOGY
Intracranial Stenosis Due to Atherosclerosis
Causes 8-10% of ischemic strokes in North America
Risk factors for intracranial stenosis
Hypertension
Race
Asian
Most common cause of stroke (33-56%)
Latino
African descent
Metabolic syndrome
Mechanisms of ischemic stroke due to intracranial stenosis
Thromboembolism distal to stenosis
In situ thrombosis at arterial stenosis
Hemodynamic hypoperfusion distal to stenosis
Perforating/branch artery occlusion by atheroma
Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study
Patients with prior TIA/nondisabling stroke from symptomatic intracranial stenosis of 50-99% severity
Randomized to warfarin or aspirin
Aspirin shown to be safer and as effective
15% stroke rate in stenotic territory over 1.8 years
44% of these strokes disabling
If stenosis ≥ 70%, stroke rate was 23%
Intracranial Stenosis Angioplasty/Stenting
Primary angioplasty (PTA) of symptomatic intracranial stenoseswithout stenting
Early studies reported high PTA-associated risks
Vessel rupture, vasospasm, dissection
Death in up to 33% of patients
Subsequently, several reports of successful PTA
Slower balloon inflation and balloon undersizing
Reduced complications
Occasionally suboptimal angiographic results
Cochrane review of 79 articles (total of 1,999 cases)
Included case series with ≥ 3 cases of 1° PTA
Overall perioperative stroke rate (7.9%)
Perioperative death rate (3.4%)
Perioperative stroke or death rate (9.5%)
1-year follow-up stroke rate (6%)
Technical disadvantages as opposed to stenting
Arterial dissection
Potential for increased thrombogenicity
Immediate elastic recoil
Higher re-stenosis rates
No trials comparing PTA vs. stenting
Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA trial)
Trial using Neurolink® (Guidant; San Francisco, CA) balloon expandable stent
Successful stent placement (95%)
30-day periprocedural stroke rate (6.6%)
6 months after stenting > 50% re-stenosis in 32% of intracranial stents
61% of recurrent stenoses were asymptomatic
Neurolink stent no longer manufactured
Wingspan study: Prospective multicenter trial
Successful stent placement (97.8%)
Self-expanding nitinol stent deployed after PTA
30-day periprocedural stroke/death rate (4.5%)
At 6-month angiographic follow-up
> 50% restenosis in 6.8%; all symptomatic
At 6-month clinical follow-up
Ipsilateral stroke/death rate (7.0%)
All strokes (9.7%)
All-cause mortality (2.3%)
FDA granted humanitarian device exemption (HDE)
Based upon results of Wingspan study
NIH Multicenter Wingspan Stent Registry
129 patients with 70–99% intracranial stenosis
Stenosis reduced to < 50% in 97% of patients
30-day stroke or death risk (9.6%)
Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS trial)
Compares safety/effectiveness of intensive medical therapy plus stenting vs. intensive medical therapy alone for intracranial stenosis
Entry criteria
Symptomatic intracranial stenosis ≥70%
TIA or stroke within 30 days
Both study arms receive dual antiplatelet therapy
Aspirin, clopidogrel for 3 months after enrolling
Intensive management of vascular risk factors
Blood pressure/cholesterol management
Enrollment stopped prematurely
Better outcomes with medical than stent group
30-day death/stroke rate: PTA/stenting (14%) vs. medical therapy (5.8%)
Trial will continue to follow enrolled subjects
PRE-PROCEDURE
Indications
Contraindications
Pre-Procedure Imaging
Getting Started
PROCEDURE
Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies
POST-PROCEDURE
Expected Outcome
Things to Do
OUTCOMES
Complications
Selected References
Al-Ali F et al: Predictors of unfavorable outcome in intracranial angioplasty and stenting in a single-center comparison: results from the borgess medical center-intracranial revascularization registry. AJNR Am J Neuroradiol. 32(7):1221-6, 2011
Li J et al: Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis. Cardiovasc Intervent Radiol. Epub ahead of print, 2011
Short JL et al: Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol. 1:160, 2011
Yu SC et al: Angioplasty and stenting of atherosclerotic middle cerebral arteries with wingspan: evaluation of clinical outcome, restenosis, and procedure outcome. AJNR Am J Neuroradiol. 32(4):753-8, 2011
Fields JD et al: Indications and applications of arterial stents for stroke prevention in atherosclerotic intracranial stenosis. Curr Cardiol Rep. 12(1):20-8, 2010
Lutsep HL: Symptomatic intracranial stenosis: best medical treatment vs. intracranial stenting. Curr Opin Neurol. 22(1):69-74, 2009
Schumacher HC et al: Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis. J Vasc Interv Radiol. 20(7 Suppl):S451-73, 2009
Bose A et al: A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 38(5):1531-7, 2007
Cruz-Flores S et al: Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev. 3:CD004133, 2006
Marks MP et al: Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke. 37(4):1016-20, 2006
Mazighi M et al: Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 66(8):1187-91, 2006
SSYLVIA Study Investigators: Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 35(6):1388-92, 2004
Connors JJ 3rd et al: Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg. 91(3):415-23, 1999
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