Angioplasty and Stenting of Severe Intracranial Stenosis Is Highly Successful

Intracranial vascular stenosis is a risk factor for cerebral infarction, and methods of treatment include conservative management, angioplasty, or angioplasty and stent.

A recent study was conducted to evaluate outcomes and factors related to adverse events following balloon expandable intracranial stent placement (BEICS).

Angioplasty and stenting of severe intracranial stenosis has proven to be highly successful

The study has shown that intracranial balloon expandable stenting is technically successful in 99% of cases. Adverse events within 6 months occur in roughly 10%, most of which are in patients who were unstable at the time of the procedure.

The Study
The retrospective review was comprised of 100 consecutive patients who underwent BEICS placement.

Methodology
All patients had symptomatic >69% intracranial stenosis. Procedural success was defined as <50% stenosis after the procedure. Adverse event occurrence was evaluated at 30 days and 6 months.

Minor stroke was defined as a new non-disabling stroke or increase in National Institutes of Health Stroke Scale (NIHSS) by 3 points but with resolution within 30 days, whereas major stroke was defined as increase by 4 points persisting >30 days.

Final outcome was defined by the modified Rankin Scale.

Patients were categorized into stable and unstable categories.

Stable was defined as those with symptoms that had resolved, were improving, or were stationary before the procedure.

Unstable was defined as progressive or fluctuating neurologic symptoms within 2 days prior to the procedure.

Results
The procedural success rate was 99%. Ten adverse events occurred within 6 months, including 4 minor strokes (4%), 3 major strokes (3%), and 3 deaths, 1 of which was due to myocardial infarction.

Of these, 9 occurred within 30 days and were ipsilateral to the stent. Mean residual stenosis was 25.2% +/- 16.2. Twenty-seven patients were in the unstable group, which correlated well with poor patient prognosis (P =0.004).

Degree of pre-stent stenosis was also associated with increased adverse events (P =0.049).

Stepwise logistic regression analysis and multivariate logistic regression models were performed using multiple clinical and technical factors, and demonstrated no significant predictive factors for outcome other than being unstable pre-procedure.

In the stable group, there were 3 adverse events (4.1%), 1 of which was major compared with 7 (25.9%) in the unstable group, 5 of which were major.

Three major strokes occurred from re-occlusion from subacute thrombosis, and 2 deaths were caused by hemorrhage following basilar artery stent.

One death occurred secondary to myocardial infarction 22 days after the procedure. At 6 months, follow-up on 59 patients demonstrated no evidence of restenosis.

Conclusions
Stent placement in intracranial arteries has a high procedural success rate of 99% and acceptable adverse event rate of 10%. Adverse events were much lower (4.1%) in stable patients than in unstable patients (25.9%).

Reviewer’s Comments
This was a well-written, comprehensive paper. The biggest drawback is the absence of a control group or comparison with alternative treatment.

For those interested, the authors discuss possible explanations of why the unstable group had a worse prognosis, and how these results compared with other studies involving conservative management and stent placement.

Author: Yaron Lebovitz, MD

Reference:

Suh DC, Kim JK, et al. Intracranial Stenting of Severe Symptomatic Intracranial Stenosis: Results of 100 Consecutive Patients. AJNR Am J Neuroradiol; 2008; 29 (April): 781-785