Role of Stenting for Intracranial Atherosclerosis in the Post-SAMMPRIS Era

Abstract

Introduction. The initial promise of endovascular stenting for the treatment of intracranial atherosclerotic disease (ICAD) has been tempered by the results of the SAMMPRIS trial which demonstrated better outcomes with medical management compared to stenting for symptomatic ICAD. We review post-SAMMPRIS ICAD stenting outcomes. Methods. A comprehensive literature search was performed using PubMed to identify all ICAD stenting series published after the SAMMPRIS in September 2011. The type and design of the stent, number of patients and lesions, inclusion criteria, and clinical and angiographic outcomes were noted. Results. From October 2011 to August 2013, 19 ICAD stenting series were identified describing the interventional outcomes for 2,196 patients with 2,314 lesions. Of the 38 different stents used, 87% were balloon-expandable stents (BESs) and 13% were self-expanding stents. The median minimum stenosis was 50%. The median rates of technical success rate, postprocedural ischemic events, and symptomatic in-stent restenosis (ISR) were 98% (range 87–100%), 9.4% (range 0–25%), and 2.7% (range 0–11.1%), respectively. The median follow-up durations were one to 67 months. Conclusions. The management of severe ICAD remains controversial. Future trials are needed to define the optimal patient, lesion, and stent characteristics which will portend the best outcomes with intervention.

Evolution of intracranial atherosclerotic disease under modern medical therapy

“…Although remodeling of intracranial plaques remains largely unknown, further studies of the natural history of ICAD are crucial for defining the indication and time window of any forthcoming treatment that aims to improve stenosis. 3,49,50 Although we provided no concurrent histological evidence of resolving inflammation, the angiographic regression might signify diminished plaque vulnerability. Assuming other physical parameters are constant, based on Poiseuille's law and a computational fluid model we applied in ICAD, 51 a 16% reduction in maximal stenosis may result in a few-fold rise in the upstream-todownstream blood flow, and a 10 to 20% decrease in shear strain rate and pre-and poststenotic velocity ratio; these improvements in local hemodynamics might be associated with a diminished risk of cerebral ischemic events 51 and partly account for the decrease in the annual stroke risk of ICAD from the second year onward.…”

Thirty-Day Outcome of a Multicenter Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China

“…Vessel segments with perforators, particularly in patients with symptoms related to ischemia in the perforator territories, carry a high risk of ischemic complication from compromised flow to the perforators. 9,10 Patients with these risk features can be identified and excluded from endovascular therapy to improve the safety of the treatment.…”

Ophthalmologic course of bilateral abducens nerve palsies after the treatment of idiopathic intracranial hypertension with venous sinus stenting

“…At our institution, a venous pressure gradient of at least 10 mmHg across the stenotic segment is necessary to be considered for VSS. In contrast to stents deployed in intracranial arteries, in-stent stenosis or occlusion rarely occurs after stenting of major dural venous sinuses, although stent-adjacent stenosis tends to develop after VSS [4][5][6]. Additionally, VSS may be more cost-effective than CSF diversion, due to a significantly lower reoperation rate [7].…”