Stenting versus medical treatment for severe symptomatic intracranial stenosis

Abstract

Background and purpose: Intracranial atherosclerosis is especially prevalent in Asians, but intracranial stent placement and medical treatment for severe intracranial stenosis are controversial. Thus, we compared long-term outcomes of these 2 therapeutic approaches in an Asian population.

Materials and methods: Patients with angiographically proved severe (≥70%) symptomatic intracranial atherosclerosis, with or without stent placement, were retrospectively reviewed at a single center between 2002 and 2009, with adjustments for age, sex, vascular risk factors, degree of baseline stenosis, and baseline functional status.

Results: Of the 114 patients followed from 3 to 36 months (mean, 17.3 months) after initial diagnosis, 53 received 56 stents in addition to medical treatment (stent-placement group), and 61 matched patients received only medical treatment (medical group). Total clinical events, including stroke, TIA, and vascular death, were 12 (22.6%) and 15 (24.6%) in the stent-placement and medical groups, respectively (P = .99). The stent-placement group had significantly better functional outcomes than the medical group (94.3% versus 78.7% for mRS scores of 0-3, P = .045). Most events in the stent-placement group occurred within the first week of the periprocedural period (17.0%) as minor embolic or perforator infarctions, and the rate of events decreased thereafter (5.7%, P = .07). Stent placement over the perforator-rich MCA and BA independently predicted periprocedural events on multivariate regression analysis. In the medical group, events increased in frequency (21.7%) and severity with time.

Conclusions: Although the total ischemic event rate was similar in the 2 groups during a 3-year follow-up, the stent-placement group had a more favorable functional outcome despite minor periprocedural strokes.

Fig 1.

A, Kaplan-Meier curve of cumulative event-free probability. Note the stent-placement group drops 17% within the first week due to periprocedural complications and then slides modestly thereafter. In contrast, the medical group declines progressively with time. After 3 years, the event-free probabilities of the 2 groups fall similarly. B, Kaplan-Meier curve of cumulative favorable probability defined as mRS scores of 0–3. Note that the stent-placement group has a markedly better long-term functional outcome (P = .045).

Fig 2.

The distribution of baseline and final mRS scores of the medical and stent-placement groups

Fig 3.

Total clinical events of different stenotic arteries subjected to stent placement. The ICA and VA were the 2 most common interventional sites. Note that the perforator-rich MCA and BA have the most clinical events.