Stenting and Prevention of Ischemic Stroke

Stenting for the prevention of atherosclerosis related ischemic strokes is a recent option in the therapeutic armamentarium. For extracranial carotid artery stenosis, stenting has proven its benefit in patients defined as “high-risk” for surgery, but beyond this specific population, surgery remains the gold standard. Based on recent prospective randomized trials, carotid endarterectomy (CEA) and carotid artery stenting (CAS) seem to share equivalent peri-procedural stroke risks, but the significantly higher rates of local nerve injury and myocardial infarction related to the surgical approach should favor the endovascular intervention in the future. In other locations, such as extracranial vertebral artery or intracranial stenoses, the current practice of care is not defined and the benefit of stenting is under investigation. However, in patients with symptomatic lesions despite appropriate antithrombotic therapy, stenting is considered to have a better benefit/risk profile in comparison to intracranial bypass surgery. In-stent restenosis (ISR), a major concern after stenting in coronary arteries, is an infrequent event following cervical internal carotid stenting but is relatively common and may worsen outcomes following treatment of extracranial vertebral and intracranial arterial stenoses. Drug eluting stents have proven their efficacy to control ISR and have changed dramatically the landscape of interventional cardiology, for this purpose their evaluation is now starting in the cerebral vasculature. The field of endovascular interventions is rapidly evolving and the development of devices dedicated to the cerebral vasculature is without any doubt going to extend the spectrum of treatable lesions.