Is aggressive medical treatment without stenting the best option for plaque build-up in the arteries of the brain?

This study looked at the effect of aggressive medical treatment with or without stenting in patients with intracranial artery stenosis.

Intracranial stenosis describes the narrowing of an artery inside the brain. It is caused by a buildup of plaque inside the artery wall that reduces blood flow to the brain and can cause a stroke. A stroke is a disturbance of oxygen to the brain that can result in cell death. Treatment for intracranial stenosis aims to reduce the risk of stroke using medications such as

• blood thinners that allow blood to flow through the arteries more easily and prevents the blood from clotting
• cholesterol-lowering drugs which reduce plaque formation
• blood pressure-lowering drugs which reduce the risk of stroke

Surgery is also available and is normally considered for patients who are at a high risk of developing stroke. Surgery involves removing or reducing the plaque buildup or enlarging the artery to allow more blood to flow. Stenting (balloon angioplasty) is minimally invasive surgery that widens the diameter of the artery. A small flexible tube is inserted into an artery in the groin and is moved along the blood system until it reaches the narrowed artery. A small balloon is then inflated within the artery to dilate it and flatten the plaque against the artery wall. 

451 patients with intracranial artery stenosis at high risk of developing stroke were assigned intensive therapy (blood thinning treatment with aspirin and clopidogrel [Plavix] and lifestyle modifications) with or without stenting. After approximately 32 months, 15% of 227 patients that did not have stenting experienced stroke or passed away. In comparison, 23% of 224 patients that underwent stenting surgery had a stroke or passed away. 

The occurrence of any stroke or major hemorrhage was higher in the group that underwent stenting than the group who did not. 

Aggressive medical management alone may have more long-term benefits for patients with high-risk intracranial artery stenosis than aggressive therapy with intracranial stenting surgery. 

While this study showed that aggressive medication treatment with stenting is not favorable to high-risk patients, mild medication treatment with stenting was not investigated and may hold some benefit.  

If you or someone you know are at a high risk of stroke, talk to a doctor about the benefits of medication with or without stenting.