What are the latest guidelines for intracranial stenting in patients with severe intracranial stenosis?

Latest Guidelines on Intracranial Stenting

Medical therapy should be the first-line treatment for patients with symptomatic intracranial stenosis, as intracranial stenting is associated with higher rates of stroke and death compared to medical management alone. 1

Current Recommendations for Intracranial Stenosis Management

Medical Therapy (First-Line Approach)

• Antiplatelet therapy:

  • Aspirin 50-325 mg daily is recommended over warfarin for patients with 50-99% stenosis of major intracranial arteries 2
  • For recent stroke/TIA (within 30 days) attributable to severe stenosis (70-99%), add clopidogrel 75 mg daily to aspirin for up to 90 days 1

• Blood pressure management:

  • Target BP <140/90 mmHg for long-term management 2, 1
  • This has been shown to reduce stroke risk (HR 0.59; 95% CI 0.40-0.79) 2

• Lipid management:

  • Total cholesterol target <200 mg/dL 2
  • High-intensity statin therapy regardless of baseline LDL levels 1
  • Lower subsequent stroke risk has been demonstrated (HR 0.69; 95% CI 0.48-0.99) with cholesterol <200 mg/dL 2

• Additional measures:

  • Smoking cessation, diabetes control, and lifestyle modifications 1

Intracranial Stenting (Limited Role)

Intracranial stenting should NOT be performed as initial treatment for patients with intracranial stenosis, even for patients who were taking antithrombotic agents at the time of stroke/TIA 1. Multiple clinical trials have consistently shown harm or no benefit:

• SAMMPRIS trial: Showed higher rates of stroke or death within 30 days in the stenting plus medical therapy group (14.7%) compared to medical therapy alone (5.8%) 3

• VISSIT trial: Demonstrated higher rates of stroke or death within 30 days in the stenting group (24.1%) compared to medical therapy (9.4%) 3

• CASSISS trial (2022): Found no significant difference in the primary outcome of stroke or death between stenting plus medical therapy (8.0%) versus medical therapy alone (7.2%) 4

Stenting may only be considered in highly selected cases with:

1. Severe stenosis (70-99%)
2. Actively progressing symptoms or recurrent TIA/stroke
3. Failure of optimal medical therapy 1

Technical Considerations When Stenting Is Performed

When stenting is deemed necessary in selected cases:

• Technical success rates are generally high (95-98%) 2, 5
• Periprocedural complication rates vary by center experience and stent type:
  • Wingspan stent: 30-day stroke/death rate of 4.5-14.7% 2
  • Balloon-mounted coronary stents: 30-day morbidity of 7.1% 5
• Restenosis remains a concern (20-32% of cases) 2, 5

Important Caveats and Pitfalls

1. Periprocedural risk: The highest risk period for stenting is the immediate periprocedural period (first 30 days), with 75% of vascular events occurring in the first postoperative week 3

2. Patient selection is critical: Avoid stenting in patients with:

   • Perforator territory strokes (brainstem or basal ganglia)
   • Very recent symptoms (<3 weeks)
   • Technically challenging anatomy

3. Operator experience matters: Procedures should only be performed at high-volume centers with significant neurovascular expertise 2

4. Extracranial-intracranial bypass surgery: This is NOT recommended for patients with 50-99% stenosis or occlusion of major intracranial arteries 1, 2

5. Follow-up: Regular monitoring with serial noninvasive imaging is essential to assess disease progression in patients managed medically 1

In conclusion, the evidence strongly supports medical management as the first-line approach for intracranial stenosis, with stenting reserved only for carefully selected patients who continue to have symptoms despite optimal medical therapy.