Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 405-407
Topic of the Issue: Case Report
Five-year follow-up of stenting for a symptomatic posterior cerebral artery stenosis
Jun Hu1, Wei Chen2, Xiaofei Zhang3, Kangning Chen1, Shugui Shi1
1 Department of Neurology, Southwest Hospital, The Third Military Medical University, Chongqing, China
Correspondence Address: Kangning Chen Gaotanyan Street 30, Shapingba District Chongqing - 400 038, Chongqing China email@example.com
Date of Submission: 03-May-2011
Code Number: ni11118
Code Number: ni11118
AbstractAngioplasty and stenting in symptomatic intracranial stenosis is technically possible and may reduce the risk of stroke in patients with symptomatic arterial stenosis. We report a patient with P1 segment stenosis of posterior cerebral artery treated successfully with angioplasty and stenting with a favorable outcome. He had 5 years of clinical and imaging follow-up and no in-stent stenosis or new ischemic event was observed.
Keywords: Posterior cerebral artery, stenosis, stent
Intracranial atherosclerotic disease is one of the common causes of ischemic strokes, especially in the Asian population.  Atherosclerotic intracranial stenoses are dynamic lesions and they may have progression as well as regression.  Angioplasty and stenting have been found to be an effective treatment option in these patients. , There are hardly any reports of treatment of posterior cerebral artery (PCA) stenosis with stenting. We report a patient with symptomatic PCA stenosis treated successfully with stenting and 5 years clinical and imaging follow-up.
A 64-year-old man was admitted for right side weakness and transient dizziness and drop attack. Medical history included left basal ganglia intracerebral hemorrhage (6 years back), hypertension, and diabetes mellitus. Head computed tomography (CT) done 2 years before the present admission showed patchy infarcts in left basal ganglia [Figure - 1]a. Neurological examination revealed right hemiplegia with alexia and agraphia. The National Institutes of Health Stroke Scale (NIHSS) score was 4. Head CT done on the day of admission showed a new ischemic infarct in the left thalamic region [Figure - 1]b.Transcranial Doppler (TCD) examination revealed peak systolic velocity (PSV) of 15 cm/sec in left PCA.
Digital subtraction angiography (DSA) done on day 5 of admission showed 85% stenosis of P1 segment of PCA [Figure - 2]a. No collaterals with meningeal arteries were observed. After evaluation of risks, benefits and treatment alternatives, endovascular treatment was suggested. Under general anesthesia, femoral artery puncture was done and arterial sheath was inserted and a 6-F guide catheter was placed into the V2 segment. Under the guidance of the road roadmap ﬂuoroscopy, a mini-guide wire (AgilityTM10, Cordis, Miami, FL, USA) was placed into the P3 segment of the left PCA through the stenotic segment [Figure - 2]b. Through guide the wire, ArthosPico (2.0 × 8 mm, amg International GmbH, Raesfeld-Erle, Germany) balloon-expandable stent was inflated at a pressure of 6 atm [Figure - 2]c. The stent was successfully placed at the stenotic P1 segment of left PCA. This resulted in a good morphological result and immediate restoration of normal blood flow. Check angiography showed complete resolution of stenotic segment of PCA [Figure - 2]d. There were no periprocedural complications. His neurological deficits improved and NIHSS score was 3. Repeat TCD indicated increase of blood flow in left PCA.
The patient was in addition put on aspirin and clopidogrel and was followed by TCD and CT at regular intervals. Clinical follow-up at 60 months revealed no further TIA or stroke and his modified Rankin Scale was 2. At 5 years after stenting, follow-up CT angiography showed good visibility and patency of stent lumen and no in-stent stenosis [Figure - 3], and the CT showed no recurrence of cerebral infarction in the left lateral PCA territory [Figure - 1]c and d.  CT perfusion examination displayed no abnormalities of rCBF [Figure - 4]a, rCBV [Figure - 4]b, MTT [Figure - 4]c, TTP [Figure - 4]d of both the cerebral hemispheres.
Prognosis of patients with thrombosis of vertebrobasilar system is poor. It is still controversial whether the endovascular treatment should be preferred in patients with arterial stenosis of vertebrobasilar system. As further progression of the stenosis may result in catastrophic stroke, aggressive treatment strategies like angioplasty should be considered, especially for high-grade stenosis.  The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study reported a risk of fatal stroke and sudden death of 10% in patients with posterior circulation intracranial stenosis and suggested that medical management may be inadequate.  In our patient, the risk of interventional treatment had been weighed against the risk of stroke and the patient had received endovascular treatment.
PCA is the most distal and longest artery of the posterior circulation. Thus, it is usually difficult to perform cerebral angioplasty and stenting in this circuit. Treatment of PCA stenosis with percutaneous transluminal angioplasty and stenting has rarely been reported. Touho et al.  reported one patient with severe stenosis of P1 segment of left PCA treated with balloon dilation. However, simple angioplasty may result in intimal laceration and acute occlusion, and long-term arterial recoil would lead to restenosis. Therefore, a combination of angioplasty and stenting was adopted in our patient. Application of stents in the treatment stenosis will result in better angiographic results. The potential benefit of stenting is to improve the long-term results of improvement of brain perfusion. Restenosis is a major problem with stenting, and restenosis is associated with a high rate of recurrent stroke.  In our patient, TCD confirmed normal blood flow in the left PCA after stenting. Follow-up CT did not show any new infarcts in the left PCA territory. CT angiography demonstrated good expansion of stent and no intra-stent restenosis. Contrast media filled well in the distal segment of stent, indicating stent patency. CT perfusion also showed good reperfusion of regional brain tissue vessels. Although PCA angioplasty presents special technical challenges, , the favorable outcomes observed in this patient suggests that stenting may be a feasible treatment option for PCA stenosis.
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