Endovascular stenting for symptomatic atherosclerotic stenosis of the anterior and posterior cerebral arteries: a case series

TL;DR

This case series explores the use of endovascular stenting for treating severe brain artery narrowing when medications fail, showing it can be technically successful but emphasizing the need for caution and further research.

Contribution

The study provides early evidence on the feasibility and safety of endovascular stenting for medically refractory atherosclerotic stenosis in the ACA and PCA.

Findings

Endovascular stenting achieved a 100% technical success rate with newer self-expanding stents in 12 patients.

One patient experienced a recurrence due to medication noncompliance, while 11 had favorable outcomes with no in-stent stenosis.

Dissection occurred in one case but resolved within 12 months, suggesting procedural safety but not generalizability.

Abstract

Symptomatic intracranial atherosclerotic stenosis (sICAS) in the anterior cerebral artery (ACA) or posterior cerebral artery (PCA) may result in disability even with the best pharmacological intervention. There is a paucity of evidence regarding endovascular procedures for sICAS associated with ACA or PCA.

From January 2022 to December 2024, 12 patients with medically refractory sICAS associated with ACA or PCA, who received percutaneous transluminal angioplasty and stenting (PTAS), were included for analysis. Exclusion criteria included (1) non-atherosclerotic stenosis, concomitant infarcts in other vascular territories, antiplatelet contraindication, a baseline modified Rankin Scale (mRS) score of 3 or above, and (2) concomitant disease with survival < 2 years. sICAS with 70–99% stenosis and 2 or more strokes in the same vascular territory, with at least 1 stroke occurring during medical therapy, is considered refractory to medical treatment. Clinical data from these patients were collected and analyzed.

In 12 patients, three stenotic lesions were in the A2 segment of the ACA, and 9 were in the P1 or P2 segments of the PCA (stenosis > 70%). All lesions were treated with PTAS (1 with the NOVA intracranial sirolimus-eluting stent system, 1 with the Neuroform EZ stent, and 10 with the Neuroform Atlas stents), achieving a 100% technical success rate (residual stenosis < 30%). Dissection with unrestricted flow occurred in 1 patient (1/12) during stent placement, which disappeared 12 months later. The follow-up time ranged from 3 to 18 months (≥ 6 months in 11 patients). In the follow-up, 1 patient suffered a recurrent stroke (8.3, 95% CI: 0.21–38.5%) due to the cessation of antiplatelet and anticoagulant medication 2 months after endovascular stenting; however, the remaining 11 patients exhibited a fair outcome with a modified Rankin Scale of 1 or 0 (91.67, 95% CI: 61.5–99.8%) and no in-stent stenosis (0, 95% CI: 0–26.5%).

Endovascular stenting with newer self-expanding stents may be feasible and procedurally safe for patients with medically refractory sICAS associated with ACA or PCA. However, this therapy should not be treated as generalizable or low-risk. Further research is necessary for these patients.

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