A Case of Acute Stroke with Symptomatic Severe ICAD

A middle-aged male came to the emergency of Max Super Speciality Hospital, Shalimar Bagh, with symptoms of gait imbalance, slurred speech, and nystagmus for four days. He consulted in some other hospital where he was managed conservatively. His MRI brain revealed acute cerebellar & pontine ischemic infarcts (posterior circulation stroke). MR Angio Brain & cerebral DSA suggested severe mid-basilar Intracranial Atherosclerotic Disease (ICAD) (>95% stenosis) & hence was put on dual anti-platelets. But considering severe stenosis with a high risk of recurrent strokes, early neuro-intervention in the form of intracranial angioplasty & stenting was planned. Submaximal angioplasty was performed successfully with an undersized balloon & deployed a coronary drug-eluting stent (DES) across the stenosis. The post-operative period was uneventful except for mild ataxia.

Symptomatic intracranial atherosclerotic disease (ICAD) constitutes ~10% of all ischemic strokes. Risk factors for recurrent ischemic strokes from ICAD include hypertension, hyperlipidemia, and the severity of the stenosis (>70%).

As the patient had symptomatic severe ICAD, timely intervention with angioplasty &/or stenting is considered a safe, effective & viable treatment option for secondary prevention of stroke.

Recent ongoing trials also favour intracranial stenting over aggressive medical management for symptomatic ICAD of 70 - 99%. Now-a-days, separate intracranial neuro stents are also available in the market, but in developing countries like India, where cost factor is a major limitation, we can use coronary bare metal or drug-eluting stents too for intracranial ICAD.