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Intracranial Stenosis Stent and Angioplasty
Carlos E. Baccin, MD; James D. Rabinov, MD
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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

                                  1. 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
                                  2. Li J et al: Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis. Cardiovasc Intervent Radiol. Epub ahead of print, 2011
                                  3. Short JL et al: Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol. 1:160, 2011
                                  4. 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
                                  5. 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
                                  6. Lutsep HL: Symptomatic intracranial stenosis: best medical treatment vs. intracranial stenting. Curr Opin Neurol. 22(1):69-74, 2009
                                  7. 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
                                  8. 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
                                  9. Cruz-Flores S et al: Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev. 3:CD004133, 2006
                                  10. Marks MP et al: Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke. 37(4):1016-20, 2006
                                  11. Mazighi M et al: Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 66(8):1187-91, 2006
                                  12. SSYLVIA Study Investigators: Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 35(6):1388-92, 2004
                                  13. 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

                                                                  1. 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
                                                                  2. Li J et al: Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis. Cardiovasc Intervent Radiol. Epub ahead of print, 2011
                                                                  3. Short JL et al: Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol. 1:160, 2011
                                                                  4. 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
                                                                  5. 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
                                                                  6. Lutsep HL: Symptomatic intracranial stenosis: best medical treatment vs. intracranial stenting. Curr Opin Neurol. 22(1):69-74, 2009
                                                                  7. 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
                                                                  8. 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
                                                                  9. Cruz-Flores S et al: Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev. 3:CD004133, 2006
                                                                  10. Marks MP et al: Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke. 37(4):1016-20, 2006
                                                                  11. Mazighi M et al: Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 66(8):1187-91, 2006
                                                                  12. SSYLVIA Study Investigators: Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 35(6):1388-92, 2004
                                                                  13. 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