Stentplasty for treating symptomatic intracranial atherosclerotic disease following failure of medical therapy.

Abstract

Endovascular treatment of intracranial atherosclerotic disease (ICAD) remains challenging due to procedural risks and stroke recurrence. Previous trials have favored aggressive medical therapy. In patients refractory to medical therapy, 'stentplasty' using expandable and retrievable devices may provide a safer alternative to balloon angioplasty by allowing controlled submaximal vessel dilation without flow arrest. We present a two-center experience using these devices for treating symptomatic ICAD refractory to maximal medical therapy. Patients with symptomatic high-grade stenosis (>70-99%) who failed medical therapy and underwent 'stentplasty' with the Tigertriever and Comaneci devices were included. Demographic data, periprocedural complications, and radiological and functional outcomes were evaluated and reported. Eighteen patients were treated, of whom 16 (89%) presented with acute ischemic stroke and two (11%) with transient ischemic attacks. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 9 (IQR 6-21). Stentplasty alone resulted in successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b-3) in 11 patients (61%); the remaining seven patients (39%) required rescue therapy with permanent stenting. Median stenosis was reduced from 95% (IQR 92-99%) before treatment to 50% (IQR 48-66%) after stentplasty, and further to 10% (IQR 10-19%) in those receiving permanent stents. One periprocedural complication occurred (6%) involving distal embolization. The median (IQR) improvement in NIHSS score from admission to discharge was 5 (0-8) points. No patients experienced recurrent ischemic strokes or reocclusions during follow-up. All achieved a modified Rankin Scale score of 0-2 at 90-day follow-up (range 30-180 days). Stentplasty using expandable and retrievable devices appears to be a safe and effective treatment option for patients with symptomatic ICAD refractory to medical therapy. While many cases can be successfully treated with stentplasty alone, a subset may require adjunctive permanent stenting to achieve optimal recanalization.