Angioplasty and stenting for primary treatment of intracranial arterial stenoses

In conclusion, endovascular techniques must be considered as a primary form of therapy for patients with identified intracranial stenotic lesions and applied in patients who are most likely to benefit from them. In doing so, issues related to the location and severity of the lesion, its cerebrovascular context (eg, patterns of collateral flow), the production of symptoms, the response or potential for medical therapy, and the local technical expertise must factor into the decision-making process, and the patients must be evaluated accordingly. At present, the ideal situation involves a patient with a severely stenotic (eg, >75%) symptomatic lesion in a technically simple location (eg, V4 segment), particularly when there is a highly experienced interventionalist available. In considering endovascular therapy for intracranial lesions, there is no surgical alternative, and thus, the only conceivable comparison of these techniques is with "best" medical treatment. Currently, there is no consensus as to what constitutes optimal medical therapy, nor is there evidence that it is better than endovascular therapy. Therefore, physicians accustomed to offering angioplasty and stenting to patients who have "failed" medical therapy (ie, have had recurrent symptoms despite optimal levels of anticoagulation), or to those who have a contraindication for long-term anticoagulation, need to address the question, "What is the price of waiting until best medical therapy fails?" Recent data suggest that this price may be quite high. To determine the right approach for each type of patient with each type of intracranial lesion, further studies of these techniques and their applications should be conducted. Finally, the ultimate acceptance of intracranial angioplasty and stenting will require a prospective comparison demonstrating if and when it is superior to existing medical treatment.