Sole Balloon Angioplasty in a Patient with Symptomatic High-Grade Atherosclerotic Left M1 Stenosis: Favorable Treatment and Course Without Symptom Recurrence or Restenosis During Follow-Up

Intracranial atherosclerotic stenosis, characterized by the narrowing of cerebral arteries due to atherosclerotic plaque formation, is a leading cause of ischemic stroke and transient ischemic attacks. Ischemic events in the context of intracranial atherosclerotic stenosis can be caused by thrombus formation on the plaque surface, hemodynamic compromise (i.e., insufficient perfusion pressure distal to stenosis), or a combination thereof. The treatment of intracranial atherosclerotic stenoses aiming to mitigate the risk of ischemic events represents a critical domain of cerebrovascular care. In recent years, both medicinal management and endovascular techniques for the treatment of intracranial atherosclerotic stenoses have seen significant advancements. Among the diverse treatment modalities available, percutaneous transluminal angioplasty has gained considerable attention as an effective strategy. Employing a low-profile, highly flexible, noncompliant balloon catheter to dilate narrowed arteries without stent implantation aims to enhance cerebral blood flow and reduce the risk of ischemic stroke. A 54-year-old patient with a past medical history of protein S deficiency was referred to our clinic after recurrent transient ischemic attacks with anomic aphasia. A diagnosis of high-grade M1 stenosis on the left side was established almost 1 year previously, leading to the initiation of dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. Initially, the condition of the patient stabilized, and subsequent follow-up MRI examinations revealed no evidence of cerebral ischemia. However, the transient ischemic attacks recurred, resulting in anomic aphasia and hypoesthesia affecting the right arm and leg. Repeat brain MRI ruled out the presence of cerebral ischemia, but given the persistence of recurrent transient ischemic attacks despite ongoing dual antiplatelet therapy, the decision was made to pursue endovascular treatment for the stenosis. Sole balloon angioplasty without stent deployment was performed under general anesthesia, without any periprocedural complications. No new cerebral ischemia or transient ischemic attacks were observed postprocedure or during the subsequent 2 years. Multiple follow-up digital subtraction angiography examinations confirmed a stable outcome of the balloon angioplasty, with a persistent lumen loss of the proximal left M1 segment of less than 50%. This chapter aims to provide insights into the procedural aspects as well as short- and midterm clinical outcomes of balloon angioplasty as a treatment modality for intracranial atherosclerotic stenoses.