Stenting in acute ischemic stroke

The introduction of permanent and then temporary stenting over the past decade has advanced our ability to revascularize occluded intracranial vessels efficiently in the setting of acute ischemic stroke. The existing data indicate that this stent-based approach to cerebral revascularization is superior to predicate devices.

Origins of stenting for acute ischemic stroke

The implantation of stents for the revascularization of large vessel occlusions in the setting of acute ischemic stroke was first described and advocated by Hopkins and Levy at the State University of New York at Buffalo.1–3 Their initial case reports and case series described the immediate and reliable revascularization of otherwise refractory intracranial occlusions with balloon-expandable coronary stents. This approach represented the beginning of a paradigm shift in the intra-arterial treatment of acute ischemic stroke.

As self-expanding intracranial aneurysm stents (Neuroform, Stryker Neurovascular, Kalamazoo, MI, USA; Enterprise, Codman & Shurtleff, Raynham, MA, USA) and the Wingspan stent (Stryker Neurovascular) became available in the USA in the early 2000s, the Buffalo group as well as Nelson and colleagues at NYU began to report individual cases of the application of these devices for the revascularization of refractory intracranial occlusions on an emergency basis.4–6 The more flexible and low profile self-expanding intracranial microstents provided a technically easier and less traumatic approach to stent revascularization and, for the most part, these devices supplanted the more rigid balloon-mounted stents for this purpose. Ultimately, larger case series were reported documenting the feasibility of this approach as well as relatively impressive outcomes despite its application as a bailout procedure employed as a last resort.6–8

While these microstents provided an efficient means of emergency revascularization, the approach also presented some significant practical and theoretical drawbacks:

1. Requirement for immediate peri-procedural as well as post-procedural antithrombotic medications. Approaches to stent-supported revascularization typically required intra-procedural IIb/IIIa inhibitors followed by post-procedural oral dual antiplatelet …