Is angioplasty a viable approach for treating symptomatic intracranial stenosis?

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Abstract

BACKGROUND

Treatment of symptomatic intracranial stenosis with antiplatelet and antithrombotic agents is associated with a high failure rate, resulting in stroke and death in a considerable proportion of patients. Endovascular therapy using primary angioplasty or stenting is a potential alternative to medical treatment of intracranial stenosis.

OBJECTIVE

To assess the immediate and long-term clinical and angiographic outcomes after primary angioplasty for symptomatic intracranial stenosis.

DESIGN AND INTERVENTION

From July 1993 to December 2004, three US medical centers recruited 120 patients with 124 symptomatic atherosclerotic intracranial stenoses; lesions were evenly distributed in the anterior and posterior circulations. The degree of stenosis varied from 50% to 95% (mean 82.2 ± 10.2%). All patients underwent angioplasty with semicompliant coronary balloons (1.5 × 9 mm to 4 × 20 mm in diameter), and they received periprocedural antiplatelet therapy and systemic anticoagulation during the procedure. At the discretion of the treating physician, 16 patients also received stents. The patients were followed up for a mean of 42.3 months (range 1-128 months), with 67 patients having at least one angiogram during the follow-up period.

OUTCOME MEASURES

Outcome measures were the degree of stenosis on angiogram, the disability score on the modified Rankin scale and the rate of stroke after treatment.

RESULTS

The degree of post-treatment stenosis in patients who received angioplasty alone ranged from 5% to 90% (mean 39.4 ± 18.7%); 59.3% of patients had <50% residual stenosis, 32.4% had 50-69% residual stenosis, and 8.3% had >70% residual stenosis. No occlusions were seen on post-treatment angiogram. Within 30 days of angioplasty, three patients had a stroke and four patients died (all deaths attributable to neurological causes), resulting in a combined periprocedural stroke and death rate of 5.8%. None of the periprocedural strokes were disabling or resulted in a change in modified Rankin score. Of the 116 patients surviving the first month, 10 patients died during the follow-up period, but no deaths were attributable to neurological causes. Furthermore, 6/116 patients had a stroke in the vascular distribution of the treated vessel, and 5/116 patients had a stroke outside the area of treatment. Six transient ischemic attacks (TIAs) were also reported during the follow-up period. The overall annual stroke rate in the treated territory was 3.2%, and the overall annual stroke rate in any territory was 4.4%. During follow-up, 12.1% of patients had a repeat angioplasty and 6.9% received a stent. At the end of the study, the modified Rankin scores were improved in 49% of patients, unchanged in 45% and reduced in 6% compared with baseline. Follow-up angiography revealed that stenosis was improved, unchanged or worsened in 26.9%, 49.3% and 23.9% of the patients, respectively, compared with the post-angioplasty angiogram.

CONCLUSION

Treatment of symptomatic intracranial stenosis with angioplasty was technically successful and associated with a low rate of subsequent stroke.

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