Endovascular Recanalization of Symptomatic Intracranial Arterial Stenosis Despite Aggressive Medical Management

Background The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. Methods Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack [TIA] or stroke) intracranial stenosis who had failed medical therapy. Patients were divided into 2 groups: patients with recurrent TIA or strokedespite medical management (group 1) versus patients presenting with a strokeand worsening symptoms (progressive or crescendo stroke) despite medical management (group 2). Results A total of 101 patients were treated in 8 strokecenters from August 2009 to May 2017. Sixty-nine presented with recurrent TIA or strokeand 32 with strokeand worsening symptoms. Successful recanalization was achieved in 84% of patients. Periprocedural strokeoccurred in 3 patients and 2 had a recurrent ischemic strokeat the 90-day follow-up. Symptomatic intraparenchymal hemorrhagesecondary to reperfusion injury occurred in 3 patients and 1 had a hemorrhagic strokeafter discharge. There were 2 periprocedural perforations that resulted in death. At 90 days, 86% of patients (64/74) did not have a recurrence of strokeand the 90-day cumulative ischemic strokerate was 6.7% with 90-day mortality of 11.2%. The 90-day favorable outcome ( modified Rankin Scalescore, ≤2) rate was 77.5%. Conclusions Endovascular recanalization of unstable intracranial atherosclerotic stenosis in patients who have failed medical therapy is feasible. Future randomized trials need to determine if recanalization is of any value for this population.