Stent-angioplasty of intracranial vertebral and basilar artery stenoses in symptomatic patients

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Abstract

Background:

To present our two-center treatment results with stent angioplasty of intracranial vertebrobasilar stenoses in symptomatic patients.

Material and Methods:

Between 2001 and 2003, 21 patients with 22 stenoses, refractory to medical therapy, who underwent elective stenting of intracranial vertebrobasilar stenoses were retrospectively analyzed. All patients had ischemic events clinically referable to the stenoses. Only high-grade stenoses of at least 80% were treated. Clinical evaluation was done based on the modified ranking scale (MRS).

Results:

In all cases, the stent deployment turned out to be technically successful and control angiography demonstrated the elimination of the high-grade stenoses. A minor residual stenoses was still detectable in six cases. According to the MRS, clinical outcome improved in the case of four patients, seemed unchanged in 14 and worsened in three. The clinical morbidity rate amounted to 14%. Clinical follow-up was available for 13 patients after 9 months with no recurrent symptoms and angiographic follow-up was available after 10 months. Re-stenoses occurred in two cases without clinical symptoms. Retreatment was not done.

Conclusion:

According to our data, stent angioplasty for symptomatic intracranial vertebrobasilar stenoses can be a treatment alternative in case of recurrent symptoms despite medical therapy; particularly, for stenoses of type Mori A or B.

Introduction

Intracranial arteriosclerosis causes ∼8% of ischemic strokes [1], [2]. Atherosclerotic intracranial stenoses are dynamic lesions that demonstrate both progression and regression [3]. The prognosis of patients with basilar thrombosis is known to be fatal. The annual risk of stroke in patients with stenoses of the intracranial vertebral is reported with 3–8% and of the basilar artery with 2.5–11% [4]. It is still controversial whether the endovascular or medical treatment (antiaggregation or anticoagulation) should be preferred [5], [6], [7]. Patients with intracranial atherosclerosis frequently suffered from cerebral ischemia while being treated with an antiplatelet agent or oral anticoagulant [8]. This risk has to be weighted against the risk of an interventional treatment.

The application of the primary stent-angioplasty (percutaneous transluminal stent assisted angioplasty, PTSA) in the treatment of atherosclerotic intracranial stenosis developed from the use of highly flexible coronary-stents for the acute treatment of complications (e.g. dissection or vessel occlusion) after angioplasty (percutaneous transluminal angioplasty, PTA).

The potential benefit of primary PTSA is to avoid these complications and to improve the long-term results of endovascular treatment of atherosclerotic intracranial stenosis [9], [10], [11]. Comparing studies between PTA and PTSA in coronary arteries have demonstrated considerably higher rates of restenosis after PTA [12]. Furthermore, using stents in the treatment of extracranial stenosis, particularly of the cervical carotid artery, has increased the safety and efficacy [13] in the treatment of atherosclerotic disease and will result in better angiographic results after PTSA [14].

Intracranial stents were also used in the treatment of wide-necked aneurysms [15], [16], [17], [18], [19], [20] and in the treatment of traumatic cavernous sinus fistulae [21] and spontaneous dural fistulae of the transverse sinus with stents [22].

In the largest collective up to now, we investigated the clinical and technical success of intracranial stenting in symptomatic arteriosclerosis of the vertebrobasilar system.

Section snippets

Patients and methods

We retrospectively analysed 21 consecutive patients (six female and 15 male, age: 67 ± 10 years), refractory to drug therapy, who underwent elective stenting of intracranial vertebrobasilar arteries between 2001 and 2003 in two centers; 22 arteries with atherosclerotic stenoses were treated. All patients had ischemic events clinically referable to the stenosis despite anticoagulation (phenprocoumon: international normalized ratio: 2–3 or intravenous heparinisation: APTT > 60 s) or antiplatelet

Results

Patient data and clinical and technical results were summarized in Table 2.

Thirteen stenosis were located at the vertebral artery and nine at the basilar artery. We ranked 10 stenosis in our population as type A, 11 as type B and one as type C. According to NASCET, 14 stenoses were 95%, six were 90% and two were 80%. In all cases, deployment of the stent was technically successful and control angiography demonstrated elimination of the stenoses. Only a residual stenosis of 5–20% was left in six

Discussion

Patients with intracranial atherosclerotic lesions have a high risk for stroke, morbidity and mortality [25]. While having therapy with anticoagulation, the risk of stroke in stenosis of the basilar artery was indicated with 10% per year [4], [26]. Drug therapy with oral anticoagulation and/or antiplatelets as the first choice therapy is just as less established as extra-intracranial bypass surgery or PTA [27], [28].

Intracranial PTSA can be assessed as a suitable procedure to prevent stroke and

Conclusion

At present, there is not enough data with a sufficient level of evidence available to come up with general recommendations for the optimal management of intracranial stenosis. According to our data, we believe that PTSA can be a treatment option for symptomatic intracranial stenoses of type Mori A and B in the posterior circulation as an alternative to drug therapy. Because there is no strict evidence for the best therapy (medical or interventional), every single case should be discussed with

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    1

    Both authors contributed equally to this work.

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