An update on interventional revascularization therapy of intracranial arterial steno-occlusive diseases

Deok Hee Lee

doi:10.5124/jkma.2012.55.9.869

J Korean Med Assoc > Volume 55(9); 2012 > Article

Lee: An update on interventional revascularization therapy of intracranial arterial steno-occlusive diseases

Continuing Education Column

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2012; 55(9): 869-877.

Published online: September 20, 2012

DOI: http://dx.doi.org/10.5124/jkma.2012.55.9.869

An update on interventional revascularization therapy of intracranial arterial steno-occlusive diseases

Deok Hee Lee, MD

Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Corresponding author: Deok Hee Lee, dhlee@amc.seoul.kr

Received August 13, 2012 Accepted August 27, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Intracranial arterial stenosis (ICAS) has been recognized as one of the major causes of ischemic stroke especially in Asian countries including Korea. There have been some arguments on the optimal management strategy over this condition. The purpose of this review is to briefly summarize its clinical significance and the current status of neurointerventional revascularization treatment. The mechanisms of stroke in ICAS are hemodynamic insufficiency, artery-to-artery embolism, athero-thrombosis, or branch artery occlusion. The first-line treatment of symptomatic ICAS is medical treatment. Balloon angioplasty followed by stent placement can be performed to improve perfusion abnormality and elimination of future embolic sources. However, a recent randomized trial on stent vs. medical management failed to show any benefit of angioplasty/stenting. Endovascular therapy is now reserved only for high-risk symptomatic cases refractory to the best medical management. High-resolution magnetic resonance imaging may help provide a better understanding of the disease and patient selection for the optimal treatment modality. Improvement of the device is mandatory to facilitate procedure safety and efficacy. The role of strict medical management which, includes risk factor modification in ICAS, has become critical. Patient outcomes could be improved if we could provide safer and efficacious technology and procedural techniques for intracranial angioplasty and stenting, especially in selected high-risk patients.

Intracranial atherosclerosis; Intracranial stenosis; Balloon angioplasty; Stent placement

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Figure 1

A case of symptomatic right middle cerebral artery stenosis treated with balloon angioplasty followed by stent insertion. A 65-year-old gentleman presented with fluctuation of left side weakness which occurred about 10 days before the procedure. (A) Initial diffusion-weighted imaging (b=1,000) shows a linear distribution of high signal spots along the anterior portion of the right internal carotid artery (ICA) internal borderzone. (B)Fluid-attenuated inversion recovery image shows not acute but recent infarction along the entire right ICA internal borderzone suggesting recurrent episodes of hemodynamic mechanism of infarction. (C) Initial right ICA angiogram shows a segmental severe stenosis of the right middle cerebral artery trunk. Significant of antegrade flow reduction is partially compensated by leptomen-ingeal collaterals from the ipsilateral anterior cerebral artery. (D) Volume rendering reconstruction image of right ICA rotational angiogram shows the stenosis vividly. The image is very helpful for the selection of optimal size of the balloon and stent. (E) Dilated balloon catheter is noted as gray tubular structure along the guidewire during angioplasty. The size of the balloon is 2 mm × 20 mm. (F) The control angiogram taken right after balloon dilatation shows mild residual stenosis. The procedure can be stopped at this point. However, we decided to insert a stent since the inner surface of the angioplasty site was a little shaggy. (G) A Wingspan stent sized 3 mm × 15 mm is deployed and both ends of the stent show dot-like radioopaque markers. (H) Control angiogram obtained right after stent placement shows mild residual stenosis, however, ante-grade flow is restored significantly. (I) Volume rendering image of computed tomography angiogram obtained the following day shows good patency of the stent. Inner lumen of the stent can easily be observed with thin-section maximum-intensity projection display (not shown).