, Volume 48, Issue 6, pp 367–372

Intracranial angioplasty and stenting for cerebral atherosclerosis: new treatments for stroke are needed!

Invited Review



Intracranial atherosclerosis is a common cause of stroke.

Intracranial angioplasty and stent revascularization

Recent technological developments offer improved methods for endovascular revascularization of symptomatic and asymptomatic cerebral artery stenosis. Identification of appropriate patients remains a diagnostic challenge, and our knowledge about the natural history of the disease remains limited.


At this time, patients with significant intracranial stenosis should receive counseling on the benefits and risks of revascularization therapy. Ultimately, determination of which patients should undergo revascularization procedures will require carefully planned, randomized clinical trials.


Cerebral atherosclerosis Stroke Angioplasty Stenting Intracranial stenosis Transient ischemic attack 


  1. 1.
    American Heart Association (2004) Heart disease and stroke statistics – 2004 update. American Heart Association, Dallas, TXGoogle Scholar
  2. 2.
    Sacco RL, Kargman DE, Gu Q, Zamanillo MC (1995) Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan stroke study. Stroke 26(1):14–20PubMedGoogle Scholar
  3. 3.
    Segura T, Serena J, Castellanos M, Teruel J, Vilar C, Davalos A (2001) Embolism in acute middle cerebral artery stenosis. Neurology 56(4):497–501PubMedGoogle Scholar
  4. 4.
    Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B (1996) Race and sex differences in the distribution of cerebral atherosclerosis. Stroke 27(11):1974–1980PubMedGoogle Scholar
  5. 5.
    Chimowitz MI, Kokkinos J, Strong J, Brown MB, Levine SR, Silliman S, Pessin MS, Weichel E, Sila CA, Furlan AJ, et al (1995) The Warfarin-aspirin symptomatic intracranial disease study. Neurology 45(8):1488–1493PubMedGoogle Scholar
  6. 6.
    Thijs VN, Albers GW (2000) Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 55(4):490–497PubMedGoogle Scholar
  7. 7.
    Chimowitz M, Lynn M, Howlett-Smith H, Stern B, Hertzberg VS, FrankelM (2004) Warfarin-aspirin symptomatic intracranial disease (WASID) trial: final results (abstract). Stroke 35(1):235Google Scholar
  8. 8.
    EC/IC Bypass Study Group (1985) Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313(19):1191–1200CrossRefGoogle Scholar
  9. 9.
    Rundek T, Elkind MS, Chen X (1998) Increased early stroke recurrence among patients with extracranial and intracranial atherosclerosis: Northern Manhattan stroke study. Neurology 50 [Suppl 4]:A75Google Scholar
  10. 10.
    Caplan LR, Gorelick PB, Hier DB (1986) Race, sex and occlusive cerebrovascular disease: a review. Stroke 17(4):648–655PubMedGoogle Scholar
  11. 11.
    Ingall TJ, Homer D, Baker HL Jr, Kottke BA, O’Fallon WM, Whisnant JP (1991) Predictors of intracranial carotid artery atherosclerosis. Duration of cigarette smoking and hypertension are more powerful than serum lipid levels. Arch Neurol 48(7):687–691PubMedGoogle Scholar
  12. 12.
    Caplan LR (2004) Advances in stroke research: basic science, treatment, and clinical trial outcomes. Rev Neurol Dis 2(1):91–94Google Scholar
  13. 13.
    Mohr JP, Thompson JL, Lazar RM, Levin B, Sacco RL, Furie KL, Kistler JP, Albers GW, Pettigrew LC, Adams HP Jr, Jackson CM, Pullicino P (2001) A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 345(20):1444–1451PubMedCrossRefGoogle Scholar
  14. 14.
    SSYLVIA Study Investigators (2004) Stenting of symptomatic atherosclerotic lesions in the vertebral or intracranial arteries (SSYLVIA): study results. Stroke 35(6):1388–1392CrossRefGoogle Scholar
  15. 15.
    Higashida RT, Hieshima GB, Tsai FY, Halbach VV, Norman D, Newton TH (1987) Transluminal angioplasty of the vertebral and basilar artery. AJNR Am J Neuroradiol 8(5):745–749PubMedGoogle Scholar
  16. 16.
    Higashida RT, Tsai FY, Halbach VV, Dowd CF, Smith T, Fraser K, Hieshima GB (1993) Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries. J Neurosurg 78(2):192–198PubMedGoogle Scholar
  17. 17.
    Terada T, Higashida RT, Halbach VV, Dowd CF, Nakai E, Yokote H, Itakura T, Hieshima GB (1996) Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries. J Neurol Neurosurg Psychiatry 60(4):377–381PubMedCrossRefGoogle Scholar
  18. 18.
    Higashida RT, Tsai FY, Halbach VV, Dowd CF, Hieshima GB (1996) Transluminal angioplasty, thrombolysis, and stenting for extracranial and intracranial cerebral vascular disease. J Interv Cardiol 9(3):245–256CrossRefGoogle Scholar
  19. 19.
    Phatouros CC, Higashida RT, Malek AM, Smith WS, Mully TW, DeArmond SJ, Dowd CF, Halbach VV (1999) Endovascular stenting of an acutely thrombosed basilar artery: technical case report and review of the literature. Neurosurgery 44(3):667–673PubMedCrossRefGoogle Scholar
  20. 20.
    Malek AM, Higashida RT, Phatouros CC, Lempert TE, Meyers PM, Gress DR, Dowd CF, Halbach VV (1999) Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement. Stroke 30(10):2073–2085PubMedGoogle Scholar
  21. 21.
    Phatouros CC, Lefler JE, Higashida RT, Meyers PM, Malek AM, Dowd CF, Halbach VV (2000) Primary stenting for high-grade basilar artery stenosis. AJNR Am J Neuroradiol 21(9):1744–1749PubMedGoogle Scholar
  22. 22.
    Gress DR, Smith WS, Dowd CF, Van Halbach V, Finley RJ, Higashida RT (2002) Angioplasty for intracranial symptomatic vertebrobasilar ischemia. Neurosurgery 51(1):23–27; discussion 27–29PubMedCrossRefGoogle Scholar
  23. 23.
    Schumacher HC, Khaw AV, Meyers PM, Gupta R, Higashida RT (2004) Intracranial angioplasty and stent placement for cerebral atherosclerosis. J Vasc Interv Radiol 15(1 Pt 2):S123–S132PubMedGoogle Scholar
  24. 24.
    Lopes DK, Ringer AJ, Boulos AS, Qureshi AI, Lieber BB, Guterman LR, Hopkins LN (2003) Fate of branch arteries after intracranial stenting. Neurosurgery 52(6):1275–1278; discussion 1278–1279PubMedCrossRefGoogle Scholar
  25. 25.
    Levy EI, Horowitz MB, Koebbe CJ, Jungreis CC, Pride GL, Dutton K, Purdy PD (2001) Transluminal stent-assisted angioplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results. Neurosurgery 48(6):1215–1221; discussion 1221–1223PubMedCrossRefGoogle Scholar
  26. 26.
    Qureshi AI, Ziai WC, Yahia AM, Mohammad Y, Sen S, Agarwal P, Zaidat OO, Suarez JI, Wityk RJ (2003) Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: a multicenter study. Neurosurgery 52(5):1033–1039; discussion 1039-1040PubMedCrossRefGoogle Scholar
  27. 27.
    Gomez CR, Orr SC (2001) Angioplasty and stenting for primary treatment of intracranial arterial stenoses. Arch Neurol 58(10):1687–1690PubMedCrossRefGoogle Scholar
  28. 28.
    Mori T, Kazita K, Chokyu K, Mima T, Mori K (2000) Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol 21(2):249–254PubMedGoogle Scholar
  29. 29.
    Nahser HC, Henkes H, Weber W, Berg-Dammer E, Yousry TA, Kuhne D (2000) Intracranial vertebrobasilar stenosis: angioplasty and follow-up. AJNR Am J Neuroradiol 21(7):1293–1301PubMedGoogle Scholar
  30. 30.
    Gomez CR, Misra VK, Liu MW, Wadlington VR, Terry JB, Tulyapronchote R, Campbell MS (2000) Elective stenting of symptomatic basilar artery stenosis. Stroke 31(1):95–99PubMedGoogle Scholar
  31. 31.
    Marks MP, Marcellus M, Norbash AM, Steinberg GK, Tong D, Albers GW (1999) Outcome of angioplasty for atherosclerotic intracranial stenosis. Stroke 30(5):1065–1069PubMedGoogle Scholar
  32. 32.
    Connors JJ 3rd, Wojak JC (1999) Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg 91(3):415–423PubMedCrossRefGoogle Scholar
  33. 33.
    Yu W, Smith WS, Singh V, Ko NU, Cullen SP, Dowd CF, Halbach VV, Higashida RT (2005) Long-term outcome of endovascular stenting for symptomatic basilar artery stenosis. Neurology 64(6):1055–1057PubMedGoogle Scholar
  34. 34.
    Henkes H, Miloslavski E, Lowens S, Reinartz J, Liebig T, Kuhne D (2005) Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (WingSpan). Neuroradiology 47(3):222–228PubMedCrossRefGoogle Scholar
  35. 35.
    Bose A (2005) The Wingspan Study. Presented at the American Society of Neuroradiology 43rd Annual Meeting, Toronto, Canada, 21–27 MayGoogle Scholar
  36. 36.
    Derdeyn CP, Grubb RL Jr, Powers WJ (1999) Cerebral hemodynamic impairment: methods of measurement and association with stroke risk. Neurology 53(2):251–259PubMedGoogle Scholar
  37. 37.
    Naritomi H, Sawada T, Kuriyama Y, Kinugawa H, Kaneko T, Takamiya M (1985) Effect of chronic middle cerebral artery stenosis on the local cerebral hemodynamics. Stroke 16(2):214–219PubMedGoogle Scholar
  38. 38.
    Grubb RL Jr, Derdeyn CP, Fritsch SM, Carpenter DA, Yundt KD, Videen TO, Spitznagel EL, Powers WJ (1998) Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 280(12):1055–1060PubMedCrossRefGoogle Scholar
  39. 39.
    Constantinides P (1967) Pathogenesis of cerebral artery thrombosis in man. Arch Pathol 83(5):422–428PubMedGoogle Scholar
  40. 40.
    Caplan LR (1989) Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology 39(9):1246–1250PubMedGoogle Scholar
  41. 41.
    Bogousslavsky J, Barnett HJ, Fox AJ, Hachinski VC, Taylor W (1986) Atherosclerotic disease of the middle cerebral artery. Stroke 17(6):1112–1120PubMedGoogle Scholar
  42. 42.
    Yanagihara T, Piepgras DG, Klass DW (1985) Repetitive involuntary movement associated with episodic cerebral ischemia. Ann Neurol 18(2):244–250PubMedCrossRefGoogle Scholar
  43. 43.
    Tatemichi TK, Young WL, Prohovnik I, Gitelman DR, Correll JW, Mohr JP (1990) Perfusion insufficiency in limb-shaking transient ischemic attacks. Stroke 21(2):341–347PubMedGoogle Scholar
  44. 44.
    Zaidat OO, Werz MA, Landis DM, Selman W (1999) Orthostatic limb shaking from carotid hypoperfusion. Neurology 53(3):650–651PubMedGoogle Scholar
  45. 45.
    Mull M, Schwarz M, Thron A (1997) Cerebral hemispheric low-flow infarcts in arterial occlusive disease. Lesion patterns and angiomorphological conditions. Stroke 28(1):118–123PubMedGoogle Scholar
  46. 46.
    Lythgoe DJ, Ostergaard L, William SC, Cluckie A, Buxton-Thomas M, Simmons A, Markus HS (2000) Quantitative perfusion imaging in carotid artery stenosis using dynamic susceptibility contrast-enhanced magnetic resonance imaging. Magn Reson Imaging 18(1):1–11PubMedCrossRefGoogle Scholar
  47. 47.
    Kim JH, Lee SJ, Shin T, Kang KH, Choi PY, Kim JH, Gong JC, Choi NC, Lim BH (2000) Correlative assessment of hemodynamic parameters obtained with T2*-weighted perfusion MR imaging and SPECT in symptomatic carotid artery occlusion. AJNR Am J Neuroradiol 21(8):1450–1456PubMedGoogle Scholar
  48. 48.
    Kikuchi K, Murase K, Miki H, Kikuchi T, Sugawara Y, Mochizuki T, Ikezoe J, Ohue S (2001) Measurement of cerebral hemodynamics with perfusion-weighted MR imaging: comparison with pre- and post-acetazolamide 133Xe-SPECT in occlusive carotid disease. AJNR Am J Neuroradiol 22(2):248–254PubMedGoogle Scholar
  49. 49.
    Ozgur HT, Walsh T Kent, Masaryk A, Seeger JF, Williams W, Krupinski E, Melgar M, Labadie E (2001) Correlation of cerebrovascular reserve as measured by acetazolamide-challenged SPECT with angiographic flow patterns and intra- or extracranial arterial stenosis. AJNR Am J Neuroradiol 22(5):928–936PubMedGoogle Scholar
  50. 50.
    Furukawa M, Kashiwagi S, Matsunaga N, Suzuki M, Kishimoto K, Shirao S (2002) Evaluation of cerebral perfusion parameters measured by perfusion CT in chronic cerebral ischemia: comparison with xenon CT. J Comput Assist Tomogr 26(2):272–278PubMedCrossRefGoogle Scholar
  51. 51.
    Kleiser B, Widder B (1992) Course of carotid artery occlusions with impaired cerebrovascular reactivity. Stroke 23(2):171–174PubMedGoogle Scholar
  52. 52.
    Silvestrini M, Vernieri F, Pasqualetti P, Matteis M, Passarelli F, Troisi E, Caltagirone C (2000) Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 283(16):2122–2127PubMedCrossRefGoogle Scholar
  53. 53.
    Cigada M, Marzorati S, Tredici S, Iapichino G (2000) Cerebral CO2 vasoreactivity evaluation by transcranial Doppler ultrasound technique: a standardized methodology. Intensive Care Med 26(6):729–732PubMedCrossRefGoogle Scholar
  54. 54.
    Mintun MA, Raichle ME, Martin WR, Herscovitch P (1984) Brain oxygen utilization measured with O-15 radiotracers and positron emission tomography. J Nucl Med 25(2):177–187PubMedGoogle Scholar
  55. 55.
    Higashida RT, Meyers PM, Connors JJ, Sacks D, Strother CM, Barr JD, Wojak JC, Duckwiler GR (2005) Intracranial angioplasty & stenting for cerebral atherosclerosis: a position statement of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, and the American Society of Neuroradiology. J Vasc Interv Radiol 16(10):1281–1285PubMedGoogle Scholar
  56. 56.
    International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360(9342):1267–1274CrossRefGoogle Scholar
  57. 57.
    Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K (2004) Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351(15):1493–1501PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Division of Interventional Neurovascular Radiology, University of CaliforniaSan Francisco Medical CenterSan FranciscoUSA
  2. 2.The Neurological Institute, New York Presbyterian Hospitals, College of Physicians & Surgeons Columbia UniversityNew YorkUSA

Personalised recommendations