Carotid and Intracranial Stenting: Preventing a Second Stroke

Age is not a criterion for us. We have treated patients in their 90s and even at 100 years of age and seen them recover. Age alone is never a reason to withhold intervention.

The key risk factors are hypertension and smoking. Blood hits the vessel wall repeatedly, the wall weakens and bulges into an aneurysm, and the body tries to repair itself — but if blood pressure is chronically elevated, or tobacco smoke is weakening the vessel wall, or there's an underlying genetic factor causing weak collagen, that repair mechanism gets overwhelmed and the aneurysm develops over time. This is different from AVMs, which are congenital and present from birth — aneurysms are acquired lesions that develop over a lifetime.

We're usually talking about narrowing at the carotid bifurcation in the neck, where the common carotid artery splits into the external carotid, supplying the face, and the internal carotid, supplying the brain. Stenosis of 50% or more on catheter angiography, or 60% or more on non-invasive imaging like CT or MR angiography, is considered significant and needs treatment. When we say severe stenosis, we mean 70% to 99% narrowing.

We work as a multidisciplinary team with a very respectful relationship with our neurosurgical colleagues. For aneurysms where both approaches are feasible, endovascular coiling is preferred under current guidelines, but we don't impose that on patients. We hold a multidisciplinary meeting, review the morphology together, discuss which endovascular option — coil, stent-assisted coil, or flow diversion — is most appropriate, and then meet the patient's family and explain the complexity, risk, and cost of each option in full so they can make an informed decision.

We need awareness at every level, not just among medical professionals but in the community, about the FAST acronym — facial drooping, arm weakness, speech disturbance, all occurring suddenly, and time. Any sudden neurological deficit, sudden severe headache, or sudden seizure requires urgent neuroimaging and immediate transfer to a centre with neuro care capability. A CT or MRI is mandatory, because you cannot distinguish an ischemic stroke from a haemorrhagic one clinically — the imaging is what tells you whether neurointervention is needed.

Secondary prevention refers to planned procedures performed after a patient has already had a stroke and the underlying vascular narrowing that caused it has been identified, aimed at preventing a second, often more severe, stroke.

A filter is first deployed downstream to protect the brain from any debris dislodged during the procedure, and a stent is then placed to open the narrowed vessel.

Intracranial stenting treats narrowing of the arteries within the skull itself. Intracranial angioplasty is technically complex and requires an experienced centre, which is why most overseas ischemic stroke patients travel specifically for these revascularisation procedures.

Because the acute stroke has already happened and the patient has stabilised, patients and their families can take time to make a calculated decision about where to be treated, unlike in an emergency setting.