Does this patient with high-grade stenosis of the distal M1 segment and symptoms of right-sided weakness require evaluation by Endovascular neurology and consideration for stenting?

Management of High-Grade Distal M1 Stenosis with Right-Sided Weakness

This patient with symptomatic high-grade stenosis of the distal M1 segment should be evaluated by Endovascular Neurology, but stenting is not recommended as first-line therapy and should be reserved only for cases failing optimal medical management.

Initial Medical Management

The current standard of care for symptomatic intracranial stenosis prioritizes aggressive medical management:

• Dual antiplatelet therapy: Initiate aspirin (50-325 mg daily) plus clopidogrel (75 mg daily) for 90 days, followed by single antiplatelet therapy thereafter 1
• Statin therapy: High-intensity statin regardless of baseline LDL, with target LDL <70 mg/dL 1
• Blood pressure control: Target <140/90 mmHg using thiazide diuretics, ACE inhibitors, or ARBs 1
• Risk factor modification: Smoking cessation, diabetes control, dietary modifications, and physical activity as tolerated 1

Rationale Against Primary Stenting

Intracranial stenting is not recommended as initial treatment for symptomatic intracranial stenosis due to:

1. Higher morbidity and mortality compared to medical management 1
2. Significant periprocedural complication rates (4.5-14.7% 30-day stroke/death rate) 1
3. High restenosis rates (20-32%) 1

When to Consider Endovascular Evaluation and Intervention

Endovascular neurology consultation is appropriate for:

• Assessment of stenosis severity and characteristics
• Monitoring for disease progression
• Determining if the patient meets criteria for intervention if medical therapy fails

Stenting may be considered only in highly selected cases:

• Severe stenosis (70-99%)
• Actively progressing symptoms despite optimal medical therapy
• Recurrent TIA/stroke despite adherence to optimal medical therapy
• Treatment at high-volume centers with significant neurovascular expertise 1

Imaging Considerations

• MRA or CTA can provide initial assessment of the stenosis 2
• Catheter-based angiography may be necessary for definitive diagnosis or to resolve discordance between noninvasive imaging findings 2
• Serial noninvasive imaging is recommended to assess progression of atherosclerotic disease 1

Follow-up Protocol

• Highest risk of recurrent stroke is within the first 30 days after the initial event 1
• Regular assessment of medication adherence and side effects
• Monitoring of risk factor control (blood pressure, lipids, etc.)
• Serial imaging to assess for progression of stenosis

Important Considerations

• Endovascular intervention should only be performed at high-volume centers with significant neurovascular expertise 1
• The 2025 guidelines from the American Heart Association emphasize that medical management remains the first-line therapy for symptomatic intracranial stenosis 1
• For patients with severe stenosis and recurrent events despite optimal medical therapy, endovascular therapy may be considered as a rescue therapy 1, 2

In summary, this patient should be evaluated by Endovascular Neurology for assessment and monitoring, but stenting should be reserved only for cases that fail optimal medical management with recurrent symptoms despite adherence to therapy.