Intracranial angioplasty and stenting: long-term results from a single center

Abstract

Background and purpose: Large-vessel intracranial atherosclerotic stenosis carries a proved stroke risk of 8%-22% per year with "best medical therapy." The long-term clinical neurologic and angiographic outcomes of angioplasty and/or stent placement for intracranial atherosclerosis in a consecutive series of patients are presented.

Methods: The demographics, procedural details, procedural outcome, and long-term neurologic follow-up in 60 consecutive patients with 71 lesions, undergoing a total of 84 procedures, were analyzed.

Results: Angioplasty alone was performed in 62 procedures; 22 procedures involved stent placement. The periprocedural stroke+death rate was 4.8%. The overall complication-free success rate was 90.5%. Restenosis occurred in 23 lesions at a mean of 4.6 months; 13 were re-treated without complication. There were 4 strokes and 4 non-neurologic deaths during 224 patient-years of follow-up. The annualized stroke rate was 1.8%, and the annualized stroke+all-cause death rate was 3.0%.

Conclusions: The stroke and death rates in this consecutive series of patients with severe intracranial atherosclerotic stenosis treated with optimal endovascular therapy are considerably less than those associated with the natural history of intracranial atherosclerosis treated with maximal medical therapy. Intracranial angioplasty with conditional stent placement is technically feasible and clinically effective with a substantial reduction in long-term stroke and death.

Figures

Fig 1.

A, 71-year-old woman who initially presented with a cerebellar infarct. Posteroanterior (PA) left vertebral arteriogram reveals a high-grade stenosis of the proximal basilar artery, supplied only by this vessel (arrow). This lesion is concentric and measures <10 mm in length and is typical of lesions responding well to angioplasty alone. B, Appearance immediately after angioplasty, illustrating that safe suboptimal improvement is satisfactory. There is residual stenosis but flow is improved. C, Appearance 6 months. The patient is still asymptomatic; no repeat angioplasty was performed. D, Appearance 7 years after angioplasty shows that the lesion is stable. The patient remains asymptomatic.

Fig 2.

A, 81-year-old man who presented with recurrent left carotid artery TIAs (right-sided weakness and expressive aphasia). PA left carotid arteriogram reveals a focal but eccentric stenosis at the petrocavernous junction (arrow). The lesion is short, eccentric, and along a curve in the vessel; the vessel is >3 mm in diameter and proximal and is typical of the lesions treated with stent placement. B, Appearance immediately after stent placement. Note a small dissection (arrow). C, Appearance 6 weeks later demonstrates healing of the dissection. D, Appearance 4 years after stent placement. The mild residual stenosis remains and the patient remains asymptomatic.

Fig 3.

A, 66-year-old man with recurrent episodes of dizziness, nausea, and diplopia. Lateral view of arteriogram performed with the catheter in the innominate artery. The right vertebral artery has a hairlike residual lumen beyond the posterior inferior cerebellar artery (small arrow); the basilar artery is supplied in large part from the anterior circulation via the posterior communicating artery (larger arrow). The dominant left vertebral is occluded just above the posterior inferior cerebellar artery. B, After initial angioplasty with a 1.5-mm balloon, distal perfusion is improved (longarrow indicating antegrade flow in the basilar artery), but a severely stenotic lumen persists (short arrows). C, After placement of overlapping stents in the distal vertebral artery, there is antegrade filling of both posterior cerebral arteries indicating increased perfusion. D, Initial follow-up examination at 6 weeks reveals continued patency. The patient was followed up with CT angiography, and the stents remain patent 2 and a half years later.

Fig 4.

Graphs indicate (A) time to restenosis, (B) time to stroke, and (C) time to death.

Fig 5.

Diffusion-weighted MR image demonstrating acute infarct (arrows) produced by intracranial stenosis of the left ICA.