Balloon Angioplasty for Intracranial Atherosclerotic Disease: A Multicenter Study

Abstract

Aim: To evaluate the role and efficacy of the balloon angioplasty in intracranial atherosclerotic disease (ICAD) in patients who presented with acute stroke due to vessel occlusion and in patients with symptomatic disease despite optimum medical management.

Methods: From 2013 to 2016, a total of 39 patients (24 males and 15 females with a mean age of 64.5 years) underwent balloon angioplasty over a period of 2 years and 8 months in three different institutions in India. Maverick balloon catheter (Boston scientific) is used in all the patients. MRI brain with MR angiogram was done in all the patients prior to intervention. Twenty-three patients who had underlying severe ICAD presented with acute stroke due to vessel occlusion. Sixteen patients presented with symptomatic ICAD with recurrent ischemic attack due to the progressing underlying disease despite optimum medical management. Technical success, peri-procedural events, and clinical outcomes were documented for all the patients.

Results: Technical success (residual stenosis < 50%) was achieved in 37 cases. Extra cranial carotid stenting was required in 2 patients. In patients with acute stroke presentation (NIHSS score median of 16.5), adjuvant intravenous and intra-arterial tissue plasminogen activator were given in 8 and 3 patients, respectively, and mechanical thrombectomy (MT) with solitaire was used in 15 patients. Patients who underwent MT in acute stroke without ICAD were not included in the study. Reocclusion occurred in one patient who developed disabling stroke and one patient died of intra-cerebral hemorrhage. Thus, the mortality of this study is 2%. Clinical outcome was assessed based on mRS. One-month, three-month, and six-month follow-up was available in >90% of the patients. MR angiogram on follow-up of nine months was done in 26 patients, and none of them had restenosis.

Conclusion: Balloon angioplasty is a safe option and can be effectively used in patients of ICAD with acceptable risks and promising outcomes.

Figure 1. Fifty-five-year-old male presented with recurrent posterior circulation transient ischemic attacks. MR DWI revealed acute infarcts in the bilateral vertebrobasilar territory as shown by arrows in (A), (B), and (C).

Figure 2. (A) DSA of patient in Figure 1 showing occlusion of basilar. (B) Residual thrombus with underlying severe stenosis after first pass. (C) Tight lesion in the basilar is seen after mechanical thrombectomy. (D) Post angioplasty angiogram showing good recanalization with patent vessel.

Figure 3. (A) Sixty-three-year-old male with acute stroke and MRI showing restricted diffusion (A) in left capsuloganglionic region. DSA done after IV thrombolysis showed total occlusion of left M1 (arrow in B) and lesion accessed with 1.5-mm maverick balloon (C) and subsequent angioplasty done with 2.5-mm maverick system (D). (B) Post-procedural angiogram showing good recanalization (E). Delayed angiogram showed good intracranial circulation (F).

Figure 3. (A) Sixty-three-year-old male with acute stroke and MRI showing restricted diffusion (A) in left capsuloganglionic region. DSA done after IV thrombolysis showed total occlusion of left M1 (arrow in B) and lesion accessed with 1.5-mm maverick balloon (C) and subsequent angioplasty done with 2.5-mm maverick system (D). (B) Post-procedural angiogram showing good recanalization (E). Delayed angiogram showed good intracranial circulation (F).

Figure 4. Fifty-five-year-old male presented with recurrent transient right MCA territory ischemic symptoms with angiogram showing critical stenosis (arrow in A and B) of right M1. Post balloon angioplasty balloon showing good antegrade circulation with residual stenosis (<50%) as seen in (C) and (D).