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Título

RECURRENT ISCHEMIC STROKE DUE TO INTRACRANIAL STENOSIS TREATED WITH BALLOON-EXPANDABLE: A CASE REPORT

RESUMO

CASE PRESENTATION: A 70 year old female with a history of ischemic stroke one year ago in the territory of middle cerebral artery, currently in using of acetylsalicylic acid and clopidogrel, presented with a new stroke in the same territory previously affected. Angiography showed stenosis of 55% of the M1 segment of the right middle cerebral artery. Due to the recurrence of ischemic events despite the double antiplatelet therapy, an endovascular treatment was chosen. The initial planning was a balloon stent, but dur-ing the procedure, it was not possible to place the stent, with only the balloon being per-formed, with good opening of the vessel and evolutionary control exams with transcrani-al Doppler showing good reperfusion and even improvement of the structural pattern of the wall of the affected vessel. The patient has evolved well, so far without new recur-rences of ischemic events, is still under medical treatment. DISCUSSION: Intracranial stenosis (ICS) is associated with a higher risk of ischemic stroke. Although the SAMMPRIS trial clearly demonstrated superiority of aggressive risk factor management plus antiplatelet therapy over intracranial stenting, the question remains regarding opti-mal treatment of those patients who develop recurrent stroke symptoms despite best medical management. A post-hoc analysis of SAMMPRIS evaluated the impact of hemodynamic markers, such as the presence of “water-shed” and impaired collateral flow on baseline imaging, and rates of recurrent stroke in the medical arm. The analysis showed that patients with poor collateral flow and baseline strokes, suggesting a hemodynamic rather than an embolic mechanism, are at most risk for subsequent stroke with medical therapy alone. This finding may help identify patients who are more likely to benefit from endovascular therapy for severe intracranial stenosis. The optimal way to determine which intracranial stenosis is “hemodynamically significant” remains to be determined. FINAL COMENTS: Intracranial stenosis is an important cause of strokes and therefore needs treatment, especially when symptomatic. Although the overwhelming majority of patients with ICS should be treated with best medical therapy, a subset of patients with recurrent strokes require endovascular revascularization by angioplasty with or without stenting.

Palavras Chave

BALLOON-EXPANDABLE; RECURRENT ISCHEMIC STROKE; INTRACRANIAL STENOSIS