Computed tomography angiography, perfusion computed tomography, and a drug-eluting stent for the treatment of in-stent restenosis of the middle cerebral artery

Case report

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The authors report a case of in-stent restenosis (ISR) of the middle cerebral artery (MCA) following bare-metal stent (BMS) deployment and subsequent treatment using a drug-eluting stent (DES). This 65-year-old woman presented with frequent transient ischemic attacks. Initial studies revealed occlusion of the left internal carotid artery and severe stenosis of the right MCA with decreased cerebral perfusion in the bilateral MCA territories. Stent-assisted angioplasty of the right MCA was performed using a BMS, and satisfactory results were obtained with no complications. Six months after the procedure the patient presented with recurrent symptoms, and workups revealed ISR with decreased cerebral perfusion. A DES was successfully placed without complications. Follow-up studies at 3 and 8 months after retreatment showed sustained luminal integrity and cerebral perfusion. A combination of CT angiography and perfusion CT exhibited the anatomical results and hemodynamic status of the stenotic lesion, and these findings coincided with the patient's clinical symptoms and the results of conventional cerebral angiography.

In-stent restenosis of the MCA after placement of a BMS can be treated using a DES. A combination of CT angiography and perfusion CT can be an alternative to conventional angiography. Low-profile devices with an amelioration of trackability are essential for the further incorporation of the DES into the field of endovascular neurosurgery. More clinical experiences and long-term follow-ups are mandatory to evaluate the safety, efficacy, and durability of the DES.

Abbreviations used in this paper: BMS = bare-metal stent; DES = drug-eluting stent; EC-IC bypass = extracranial-intracranial bypass surgery; ICA = internal carotid artery; IAS = intracranial atherosclerotic stenosis; ISR = in-stent restenosis; MCA = middle cerebral artery.

Article Information

Address correspondence to: Seong-Rim Kim, M.D., Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Sosa-dong 2, Wonmi-gu, Bucheon, Kyeonggi-do, 420-717, Republic of Korea. email:

Please include this information when citing this paper: published online September 11, 2009; DOI: 10.3171/2009.8.JNS081609.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Upper: Cerebral angiogram obtained in a 65-year-old, left-handed woman, revealing ICA occlusion at the cervical portion and severe stenosis (> 70%) of the right MCA. Bilaterally decreased cerebral perfusion was identified on SPECT. She underwent stent-assisted angioplasty using a BMS for the right MCA stenosis. Lower: Right ICA angiogram obtained after BMS placement, demonstrating sufficient lesion expansion. Postoperative SPECT showed increased cerebral perfusion in the right MCA territory.

  • View in gallery

    Six months after BMS implantation, the patient's symptoms recurred. A CT angiogram (A) and perfusion CT scan (B) showing restenosis of the right MCA combined with decreased cerebral perfusion. Cerebral angiogram (C) confirming ISR of the right MCA. Angiogram (D) obtained after DES deployment, showing restoration of luminal integrity with adequate expansion of the lesion. Computed tomography angiogram (E) confirming the same finding. Postoperatively, cerebral perfusion in the right MCA territory was increased, and no procedure-related complication was found on diffusion weighted MR imaging.

  • View in gallery

    A CT angiogram (A) and perfusion CT scan (B) obtained the 3rd and 8th month after DES placement, revealing sustained luminal integrity of the right MCA with sustained cerebral perfusion. A right ICA angiogram (C) obtained the 8th month after the procedure, showing that the expanded lesion was maintained.


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