Intracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusions (LVO). Mechanical thrombectomy has been the gold standard for treatment of embolic LVO’s and has improved neurologic outcomes. However, when a LVO is a direct result of in situ ICAD, thrombectomy alone may not be sufficient due to high risk of re-occlusion after recanalization. Intracranial rescue stenting in these cases can minimize neurologic disability. There is no randomized controlled trial (RCT) for rescue stenting in LVO secondary to ICAD and no current guidelines with regards to timing of stenting.

61-year-old male with diabetes and hypertension presented with expressive aphasia, right upper extremity weakness, and a right facial droop with a NIHSS of 5. CT head demonstrated an ASPECTS of 9, no hemorrhage seen. CT angiography showed a left M1 occlusion. He was outside the treatment window for IV tPA but underwent emergent endovascular aspiration only thrombectomy with TICI3 reperfusion.

Post-thrombectomy angiography showed minimal atherosclerotic plaque at the occlusion site with excellent antegrade blood flow. Maximal medical therapy (Aspirin, Clopidogrel, Atorvastatin) was initiated given the non-flow limiting plaque. MRI brain showed a small left MCA stroke. 

Three hours later, NIHSS worsened from 0 to 10 from left M1 re-occlusion. Repeat thrombectomy was performed with TICI3 reperfusion. Given underlying ICAD at the re-occlusion site, an emergent intracranial stent was placed. NIHSS was now 2. After a week at a rehab center, NIHSS was 0. He is currently completely independent.

LVO secondary to ICAD is unlikely to resolve with thrombectomy alone given the high risk of re-occlusion. Stenting after a re-occlusion can demonstrate successful outcomes. Timing of stenting is difficult to determine in those with complete recanalization and reperfusion without any residual flow limiting stenosis.  RCTs are needed to establish standard of care guidelines regarding rescue stenting in LVO-ICAD.