Urgent Balloon Angioplasty/Stenting for Atherosclerotic Intracranial Vertebrobasilar Occlusive Lesions in Patients with Acute Stroke

The symptoms of acute stroke patients with atherosclerotic intracranial vertebrobasilar occlusive lesions (IVBO) frequently worsen despite medical treatment. However, timing of percutaneous transluminal balloon angioplasty (PTA)/stenting is difficult to decide, especially when the symptoms are minimal. We investigated patient selection, procedure timing and problems of PTA/stenting for acute IVBO. We retrospectively reviewed 19 patients―6 with near occlusion (NO) and 13 with complete occlusion (CO)―who underwent urgent PTA/stenting (Group A). Deterioration of the symptoms was observed in 14 patients (74%). Technical success was achieved in 17 patients including PTA in 4 and stenting in 13 (NO 100% vs. CO 85%). Recurrent stroke did not occur in any of the patients, though 2 patients underwent re-treatment. Symptomatic complications occurred in 6 patients, including distal embolism in 3 (NO 1, CO 2), medullary hemorrhage in 1 (CO), hemorrhagic infarction in 1 (CO), and subacute thrombosis in 1 (CO). Favorable outcomes (mRS≦2) were obtained in 8 patients (NO 83% vs. CO 23%, P＜0.05). The causes of the poor outcome of CO were delay of the PTA/stenting and periprocedural complications. We also retrospectively reviewed 23 patients, 14 with high-grade stenosis, 3 with NO and 6 with CO, who underwent medical treatment in acute phase of the stroke (group B). Recurrent stroke occurred in 9 patients (10.6%/year). Eight patients underwent PTA/stenting in the subacute or chronic phase, and recurrent stroke did not occur. Analysis of the angiographic findings in patients with CO showed that symptoms seemed to deteriorate when the retrograde flow into the anterior inferior cerebellar artery was not recognized even if the initial symptoms were mild. Urgent PTA/stenting for the patients with NO is a safe and effective treatment option. However, the outcome of the patients with CO is unfavorable. Patient selection, procedure timing and reduction of the complications are critical factors to improve outcomes.