Outcome of endovascular treatment in symptomatic intracranial vascular stenosis

Abstract

Objective: The outcome evaluation for the revascularization of intracranial vascular stenoses has not been fully described due to the highly technical nature of the procedure. We report here on the early and late clinical outcomes of angioplasty and/or stenting of symptomatic severe intracranial vascular stenoses at a single institute.

Materials and methods: Since 1995, we have treated 35 patients with symptomatic intracranial vascular stenosis (more than 70% stenosis, mean stenosis: 78.6%+/-6.2%). Angioplasty (n = 19) was performed for the horizontal segment of the middle cerebral artery (M1) (n = 16) and the basilar artery (BA) (n = 1), the intradural vertebral artery (VA) (n = 1), and the cavernous internal carotid artery (ICA) (n = 1). Stenting (n = 16) was performed for the cavernous or petrous ICAs (n = 9), the intradural VA (n = 3), BA (n = 2), and M1 (n = 2) artery. We assessed the angiographic success (defined as residual stenosis < 50%) rate, the periprocedural complications during the 30-day periprocedural period, the symptomatic recurrence and restenosis during a mean 22-month follow-up (FU) period. The Kaplan-Meier estimate of the cumulative event-free rate of the major cerebrovascular events, i.e. death, stroke or restenosis, was also done.

Results: Angiographic success was achieved in 97% of our patients (34/35). There were four procedure-related complications (11%) including a death and a minor stroke. During the mean 22-month FU, the asymptomatic restenosis rate was 9% and the symptomatic restenosis rate was 6% in the target lesion and 9% in all the vascular territories. The Kaplan-Meier estimate was 70.6% (95% confidence interval = 46.5-94.7) after 33 months of FU.

Conclusion: In addition to a high angiographic success rate and an acceptable periprocedural complication rate, intracranial angioplasty and/or stenting revealed a relatively low symptomatic recurrence rate. Hemorrhage is a rare, but the physician must aware that potentially fatal periprocedural complications can occur.

Fig. 1

A 60-year-old female patient presented with dysarthria and right arm weakness of 20 days duration. A. The anterioposterior view of the left internal carotid arteriogram shows a severe stenosis of the horizontal segment of the left middle cerebral artery. B. The flow improves after angioplasty. C. MR angiogram obtained 68 months later reveals good patency of the horizontal segment of the left middle cerebral artery. She had no symptom recurrence and no residual symptoms.

Fig. 2

A 62-year-old male presented with right side weakness and global aphasia. A. Angiogram of the left internal carotid artery shows a severe stenosis in the horizontal segment of the left middle cerebral artery. B. The angiogram obtained after angioplasty shows the relieved stenosis and improved flow. The patient's symptoms slowly improved except for some mild weakness and expressive aphasia that remained after there was symptom aggravation two years later. C. MR angiography obtained at the time of the symptom aggravation reveals complete occlusion of the left horizontal segment of the left middle cerebral artery.

Fig. 3

A 49-year-old male presented with the left arm weakness. A. Lateral view of the right internal carotid arteriogram shows a severe stenosis of the cavernous segment of the internal carotid artery. B. Post-stenting angiogram shows no residual stenosis. C. One-year follow-up angiogram shows good patency of the stented segment of the internal carotid artery with a 20% stenosis at the distal stent margin. Note a patent side branch of the cavernous segment of the internal carotid artery. The patient recovered completely and had no symptom recurrence during the one-year follow-up period.