Submaximal angioplasty and staged stenting for severe posterior circulation intracranial stenosis: a technique in evolution.
BACKGROUND
Severe medically refractory intracranial stenosis portends a grave prognosis. Recent advances in stent technology have enabled clinicians to treat these lesions. Evidence in the coronary literature suggests that stenting without predilation angioplasty is as safe and effective as stenting immediately preceded by predilation angioplasty for the treatment of severely stenotic lesions. Because of marked differences in vessel histology and differences in the sensitivity of the cerebral and coronary vascular beds to embolic insult, direct stenting of severe intracranial stenoses may be more prone to neurological complications than a conventional or staged stenting procedure.


METHODS
We reviewed our clinical experience with conventional, direct, and staged stenting for high-grade stenoses involving the posterior intracranial circulation. We also reviewed the literature and experimental data supporting the rationale for staged stenting.


RESULTS
In our experience, no permanent neurological morbidity was identified in four patients treated with a staged approach. In contrast, one of three patients with conventional stenting of the basilar artery and two of four patients treated with direct basilar stenting had permanent neurological sequelae.


CONCLUSIONS
For patients with high-grade posterior circulation intracranial stenoses involving the perforator-rich zones of the basilar artery, staged stenting may reduce procedure-related morbidity. A staged approach allows for plaque stabilization resulting from post-angioplasty fibrosis, which may protect patients from "snow-plowing," embolic shower of debris, or dissection. Further clinical, in vivo, and histological investigation is warranted.
Levy
Elad I
EI
Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, Kaleida Health/Millard Gates Hospital, University at Buffalo, State University of New York, Buffalo, New York 14209, USA.
Howington
Jay U
JU
Engh
Johnathan A
JA
Hanel
Ricardo A
RA
Levy
Naveh
N
Kim
Stanley H
SH
Gibbons
Kevin J
KJ
Guterman
Lee R
LR
Hopkins
L Nelson
LN
D000800:Angioplasty, Balloon / Q000379:methods*; D002548:Cerebral Revascularization; D006801:Humans; D002537:Intracranial Arteriosclerosis / Q000150:complications / Q000601:surgery*; D015607:Stents; D014715:Vertebrobasilar Insufficiency / Q000209:etiology / Q000601:surgery*