High risk of recurrent ischemic events among patients with deferred intracranial angioplasty and stent placement for symptomatic intracranial atherosclerosis

BACKGROUND: Intracranial angioplasty with or without stent placement has been performed to treat patients with recurrent cerebral ischemic events despite best medical therapy or those with high-grade stenosis. OBJECTIVE: To evaluate early recurrent stroke/transient ischemic attack rates in a cohort of patients with symptomatic >50% intracranial stenosis in whom intracranial angioplasty and stent placement was initially deferred. METHODS: All patients presenting to 2 academic hospitals with symptomatic intracranial disease between 2006 and 2008 who underwent catheter angiography were identified. Patients with complete intracranial occlusion or stenosis less than 50% stenosis were excluded (n = 14). RESULTS: Thirty-one patients met the study criteria. Sixteen (52%) patients were on antiplatelet medications at the time of the initial event, and 2 patients were also on anticoagulant medications. Six patients (19%) underwent intracranial angioplasty and/or stent placement with their initial diagnostic angiogram. Twenty-five patients (81%) had endovascular treatment deferred for best medical treatment in the interim period. Among the 25 patients who were kept on medical management, 14 (56%) were readmitted with recurrent ischemic events in the distribution of the target artery within a median of 28 days (range, 1-243 days). Recurrent events occurred within 1 week in 8 (57%) patients, between 7 days and 1 month in 4 (29%) patients, 1 to 3 months in 1 (7%) patient, and after 3 months in 1 (7%) patient. Recurrent ischemic events were observed in all 5 patients with basilar artery stenosis and in 13 of 17 patients with severity of stenosis ≥70%. CONCLUSION: A high rate of recurrent ischemic events was observed among patients in whom endovascular treatment was deferred, particularly those with basilar artery stenosis and those with high-grade stenosis. This information would be beneficial in decision making for timing of the endovascular treatment among patients with symptomatic intracranial stenosis.