J Cerebrovasc Endovasc Neurosurg.  2014 Sep;16(3):166-174. 10.7461/jcen.2014.16.3.166.

Primary Angioplasty for Symptomatic Atherosclerotic Middle Cerebral Artery Stenosis

• Chang YH
• Hwang SK
• Kwon OK

• KMID: 1963153
• DOI: http://doi.org/10.7461/jcen.2014.16.3.166

Abstract

OBJECTIVE
The objective of this study is to evaluate the clinical and angiographic outcomes after primary balloon angioplasty in patients with symptomatic middle cerebral artery (MCA, M1 segment) stenosis refractory to medical therapy.
MATERIALS AND METHODS
Eleven patients with intracranial stenosis were treated with primary balloon angioplasty. All patients had MCA stenosis with recurrent transient ischemic attack (TIA). The indication for balloon angioplasty was patients with significant MCA stenosis: 1) age older than 18 years with recurrent or progressive TIA or infarction despite optimal medical therapy, including anti-coagulation, dual anti-platelet, and anti-lipid medication; 2) previous ischemic events or asymptomatic severe stenosis (more than 50%) with poor collateral cerebral circulation, or diminished cerebral perfusion on single photon emission computed tomography before and after administration of the intravenous dosage of acetazolamide.
RESULTS
The median age of patients was 53 years (range 44-79). The technical success rate was 100%. Mean pretreatment stenosis degree was 83.63 +/- 9.53% and 29.1 +/- 15.4% before and after angioplasty, respectively. Procedural-related complications occurred in four of 11 patients (36%), but none of the patients had permanent neurological deficit. All patients were available for an average follow-up period of 19.4 +/- 5.1 months. One patient had a stroke in the territory of angioplasty at two months after angioplasty. The stroke free survival rate at 30 days and 12 months was 100% and 91%, respectively. Restenosis over 50% was observed in three of 11 patients (27%); all were asymptomatic.
CONCLUSION
Intracranial angioplasty for symptomatic MCA stenosis refractory to medical therapy can be a treatment option to reduce the risk of further TIA or stroke.

Keyword

Balloon angioplasty; Middle cerebral artery; Intracranial stenosis; Atherosclerosis

MeSH Terms

Acetazolamide
Angioplasty*
Angioplasty, Balloon
Atherosclerosis
Constriction, Pathologic*
Follow-Up Studies
Humans
Infarction
Ischemic Attack, Transient
Middle Cerebral Artery*
Perfusion
Stroke
Survival Rate
Tomography, Emission-Computed, Single-Photon
Acetazolamide

Figure

• 

  Fig. 1 A 56-year-old woman had recurrent transient ischemic attack (TIA) symptoms refractory to medical treatment. (A) Anteroposterior left internal carotid artery (ICA) angiogram shows severe stenosis (> 50%) in the proximal M1 portion of the left middle cerebral artery (MCA). (B) Angioplasty balloon is performed successfully. (C) Postprocedural ICA angiogram shows the MCA with a smooth appearance, widened or increased luminal diameter (residual stenosis about 30%), and preservation of the lenticulostriate arteries. (D) After angioplasty, the patient developed weakness of the upper extremity. Anteroposterior left ICA angiogram shows stagnation of distal MCA cortical flow, possibly due to multiple distal emboli. (E) After chemical thrombolysis (urokinase 200,000 IU and tirofiban Hydrochloride 300 µg), weakness of upper extremity shows improvement (grade 5). (F) Angiogram 15 months after the procedure does not show significant re-stenosis.

• 

  Fig. 2 A 53-year-old man had recurrent TIA symptoms refractory to medical treatment. (A) Anteroposterior left ICA angiogram shows severe stenosis (approximately 90%) in the proximal M1 portion of the left MCA. (B) Angioplasty balloon was deployed successfully. During angioplasty, an angiogram demonstrates dissection of MCA. However, the patient did not show any neurological deficit. (C) Postprocedural ICA angiogram (delayed 30 minutes) shows the MCA with a smooth appearance, widened luminal diameter (residual stenosis about 50%), and preservation of the lenticulostriate arteries. (D) Magnetic resonance angiogram at 23 months after the procedure shows restenosis (approximately 60%). However, the patient had no ischemic event.

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