Review Article
Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105556Get rights and content

Highlights

  • Intracranial stenting, still a viable option for the treatment of ICAD in selected patients.

  • Operator expertise and selection criteria are critical to optimize the outcomes of intracranial stenting.

  • In-stent restenosis can be safely treated with stenting versus balloon angioplasty.

Abstract

Objectives/Background

Medical therapy is the first line of treatment for intracranial atherosclerotic disease (ICAD). Percutaneous transluminal angioplasty and stenting (PTAS) are mainly considered for those patients with severe stenosis and recurrent events despite aggressive medical therapy. In this review, we discuss the application of PTAS as a treatment option for ICAD and its future prospect.

Materials and Methods

We did the literature review of the key articles and guidelines to elaborate on the role of PTAS in the management of ICAD based on the current data and expert opinion. We searched PubMed, Google Scholar, and Scopus up to August 2020, and included articles published only in the English language.

Results

Since the publication of the results from SAMMPRIS and VISSIT trials, stenting is no longer recommended for secondary stroke prevention in patients with symptomatic ICAD. However, recent clinical studies on intracranial stenting for a subgroup of ICAD patients have shown promising results, likely due to better patient selection and continued advancement of endovascular techniques.

Conclusion

There exists a lack of consensus regarding the best endovascular treatment approach (e.g., angioplasty alone or balloon mounted stent vs. self-expanding stent with or without prior angioplasty) or management of in-stent restenosis. Another area of clinical controversy relates to the ideal use and duration of antiplatelet therapy.

Introduction

Intracranial atherosclerotic disease (ICAD) is an important cause of large vessel disease leading to acute ischemic stroke (AIS). Currently, medical management such as risk factor control, antiplatelet therapy, and lifestyle changes are considered the first-line of treatment to prevent transient ischemic attack (TIA) or AIS.1 The results of the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial2 demonstrated that symptomatic ICAD is a high-risk cause of recurrent stroke and highlighted the need for better treatment strategies, leading to consideration for both better medical management and the possibility of angioplasty and stenting. The Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial3 and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial4 were designed to compare the percutaneous transluminal angioplasty and stenting (PTAS) versus aggressive medical management as the first line of treatment for ICAD. However, both trials demonstrated a higher rate of recurrent AIS and death in the PTAS group compared with aggressive medical management. The SAMMPRIS trial had a 1-year primary end-point (stroke or death) of 20.0% in the PTAS arm vs. 12.2% in the medical arm (p=0.009), and VISSIT trial showed 36.2% in the PTAS arm vs. 15.1% in the medical arm at 1-year (p=0.02). Following the outcome of the SAMMPRIS trial, the indications for PTAS were narrowed and remained an option for those patients with severe stenosis and recurrent AIS despite aggressive medical therapy.5,6 However, criticisms have been raised regarding SAMMPRIS trial's study design, including the lack of lead-in phase, inconsistent operators' experience, and patient selection criteria.7 In contrast, the Chinese multicenter registry study of stenting for symptomatic ICAD demonstrated the safety of PTAS and a low event rate with a 1-year stroke recurrence probability of 8% (5.8% nonfatal stroke and 1.1% fatal stroke) at 1-year follow-up for patients with severe symptomatic ICAD combined with poor collaterals.8,9 The results of the Wingspan Stent System Post Market Surveillance (WEAVE) trial10 demonstrated a higher technical success rate and lower than expected periprocedural event rate (2.6%) of stroke, intracerebral hemorrhage (ICH), and death. The 1-year follow-up showed a low (8.5%) rate of stroke recurrence and death in 129 stented patients.11 Moreover, the preliminary results from the China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) trial12 showed a 100% success rate of stent placement with <50% residual stenosis and a 2% rate of stroke and/or death at one month (Table 1). These results suggest that proper patient selection and increased operator experience could significantly decrease the rate of complications associated with intracranial stenting. In this review, we discuss the clinical trials on endovascular treatment of ICAD and its future prospective.

Section snippets

Neurobiology and natural history of the ICAD

Atherosclerosis is a major cause of stroke, myocardial infarction, and peripheral ischemic disease. It is a vessel wall progressive inflammation that starts early in life and is caused by the accumulation of the oxidized low-density lipoprotein in the intima. This initiates a series of complex biochemical and inflammatory reactions resulting in accumulation of the extracellular matrix, activation of the endothelium, infiltration of monocytes and T cells, intimal thickening, and fibrous cap

Self-expandable versus balloon mounted stent for the treatment of ICAD

The self-expandable Wingspan Stent System is the only FDA approved stent for the treatment of ICAD; under strict indication with safety and efficacy reported in recent trials.10,11 However, the stent design exert a lower radial force, and it is less suitable to achieve the ideal luminal dilatation, especially in rigid arteries with calcified plaques that lead to higher rates of in-stent restenosis (ISR).26,27 A drug-eluting balloon mounted stent has been used in other vessels including the

Submaximal angioplasty for ICAD

The results of recent trials on intracranial stenting for the treatment of symptomatic ICAD is promising.9,11 Some of these studies attempted to improve outcomes using primary balloon angioplasty alone, to perform submaximal or undersized inflation. Peng et al.31 in a retrospective study evaluated the peri-procedural complications and long-term stroke recurrence rate of symptomatic ICAD patients (n=129) who underwent submaximal primary angioplasty. Angioplasty was considered for patients with

Acute ischemic stroke with underlying severe ICAD

Severe ICAD can be the underlying cause of occlusion refractory in AIS after mechanical thrombectomy. Moreover, even if reperfusion is achieved by mechanical thrombectomy, immediate re-occlusion occurs frequently and optimal treatment of ICAD in this setting remains unclear.34 Generally, large vessel occlusion (LVO) due to underlying ICAD requires a two-step endovascular approach 1) initial mechanical thrombectomy to achieve primary recanalization and 2) secondary rescue therapy such as

Post stenting management of ICAD

The duration of dual-antiplatelet therapy (90 days of 325 mg aspirin and 75 mg clopidogrel per day) in the SAMMPRIS trial was in both arms. There is no consensus regarding treatment indication and strategies for intracranial ISR, duration of antiplatelet therapy after stent deployment, and lifestyle modification measures. The ISR typically reaches its peak severity between 3 to 6 months after stent deployment and has been attributed to vascular smooth muscle cell proliferation.38 It is

Future directions

In secondary prevention of ICAD, a better selection of patients for PTAS appears to be paramount to obtain better radiological and clinical outcomes with minimal to acceptable risks (see Table 2). Moreover, other aspects that could potentially improve the prevention of AIS due to ICAD include optimizing the treatment-window following stroke or TIA, improvement in techniques and device design, novel therapeutic approaches in the treatment of hypercholesterolemia, antiplatelet regimen, and

Discussion

The role of PTAS in the treatment of ICAD, the management of its complications, and the long-term clinical and angiographic luminal changes has not yet been fully delineated. In contrast to SAMMPRIS and VISSIT trials, recent trails including WEAVE, WOVEN and CASSISS have shown the safety of PTAS with decreased rate of stroke and death versus aggressive medical treatment with refined inclusion/exclusion criteria and experienced operators for the treatment of ICAD. The radial force exerted by

Source of funding

None.

Author contributions

All authors contributed equally to this work and performed the manuscript preparation, editing, and review.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

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