**11. Cerebral atherosclerotic stenoses**

The development of angioplasty and stenting was influenced by the early work of endoluminal dilation of peripheral atherosclerotic disease. Until 1980, cerebral transluminal balloon catheter dilatation was reported to treat two patients with frequent, severe, progressive symptoms despite anticoagulation and high-grade intracranial atherosclerotic stenosis (ICAS) of the basilar artery [72]. The excellent angiographic and short-term clinical in these two patients and the prevalence of ICAS had favored further research of this approach. Unfortunately, frequent complications were reported in the next case series, including arterial dissection with consecutive thrombosis or rupture, residual stenosis due to sequestration or vessel recoiling and acute or subacute vascular occlusion due to the formation of a wall hematoma [72]. In order to reduce periprocedural complications of angioplasty alone, the rigid coronary Palmaz-Schatz stent was introduced for the first time in 1996 in a patient with recurrent TIA caused by severe ICAS of the right carotid artery despite antiplatelet and anticoagulant therapy [73]. The stent deployment led to a better angiographic result compared to angioplasty alone.

The first self-expanding, nitinol-composed Wingspan stent (Boston Scientific, Fremont, CA, USA) was approved by the US Food and Drug Administration (FDA) for patients with 50% or higher ICAS, symptomatic despite medical therapy in 2005 [74]. These patients might benefit from endovascular therapy since their plaques might not stabilize with best medical therapy alone and cause recurrent artery-toartery embolic strokes. The development of new angioplasty balloon catheters and flexible stents has redefined the management strategy for symptomatic intracranial stenosis. A growing number of studies have reported a low complication profile and satisfactory rates of angiographic patency at follow-up [75].

*The History and Development of Endovascular Neurosurgery DOI: http://dx.doi.org/10.5772/intechopen.97139*

#### **Figure 14.**

*A 79-year-old man presented with dizziness. a, CT perfusion image showing the low perfusion of the right cerebral hemisphere. b, right carotid artery angiogram showing the severe stenosis of the internal carotid artery. c, right carotid artery angiogram showing the stenosis was treated with angioplasty and stenting.*

#### **Figure 15.**

*A 64-year-old man presented with transient ischemic attack. A, left internal carotid artery (ICA) angiogram (anteroposterior) showing a severe stenosis of the M1 segment of the middle cerebral artery (arrow). B, under roadmap image showing a XT27 catheter (Stryker, USA) was advanced to the distal middle cerebral artery after balloon angioplasty (arrow). C, left internal carotid artery angiogram confirming the reconstitution of the middle cerebral artery (arrow). D, fluoroscopic view of the head showing the placement of a Neuroform EZ stent (arrow).*

Angioplasty with stenting of carotid stenosis does not require general anesthesia and requires only a few seconds of carotid artery occlusion. Endoluminal revascularization has been proposed for the treatment of carotid stenosis in high-risk patients such as those with contralateral carotid occlusion [76], postendarterectomy stenosis [77], and/or severe coronary and other systemic diseases [78]. In a metaanalysis by Texakalidis et al. in 2018 including 13 comparative studies, compared to carotid artery endarterectomy carotid artery stenting had a lower incidence of cranial nerve injury, the two treatment approaches were similarly safe in terms of periprocedural stroke, myocardial infarction and death rates and carotid artery stent was associated with decreased restenosis risk (defined as either 60% or 70% stenosis) in the follow-up; however, without a significant difference in the risk of target lesion revascularization [79].

At present, we suggest that endovascular therapy may be considered as a treatment option for patients with recurrent ischaemic stroke despite best medical therapy and especially if pathophysiologically attributed to hypoperfusion with/ without bad collaterals [80] (**Figures 14** and **15**). In future, better experience of interventionalists and improved features of stents deployed are also expected to boost outcome of endovascular therapy in ICAS.
