ENRG COLLECTION: ENDOVASCULAR VIDEO SERIES Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video Rimal H. Dossani, MD ∗ ‡ , Muhammad Waqas, MBBS ∗ ‡ , Justin M. Cappuzzo, MD ∗ ‡ , Ashish Sonig, MD, MS, MCh ∗ ‡ , Adnan H. Siddiqui, MD, PhD ∗ ‡§¶|| , Elad I. Levy, MD, MBA ∗ ‡§¶|| , Jason M. Davies, MD, PhD ∗ ‡¶||# , on behalf of the Endovascular Neurosurgery Research Group (ENRG) ∗ Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Bufalo, Bufalo, New York, USA; ‡ Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Bufalo, New York, USA; § Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Bufalo, Bufalo, New York, USA; ¶ Canon Stroke and Vascular Research Center, University at Bufalo, Bufalo, New York, USA; || Jacobs Institute, Bufalo, New York, USA; # Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Bufalo, Bufalo, New York, USA Correspondence: Jason M. Davies, MD, PhD, Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Bufalo, 100 High St, B4, Bufalo, NY 14203, USA. Email: jdavies@ubns.com C  Congress of Neurological Surgeons 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demon- strate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials. 1 , 2 Submaximal angioplasty has also been described. 3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient’s symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-confgured Synchro-2 microwire (Stryker). Because of the patient’s recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion defcit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. C University at Bufalo Neurosurgery, September 2020. With permission. KEY WORDS: Intracranial atherosclerosis, Intracranial stenting, Mechanical thrombectomy, Submaximal angioplasty Operative Neurosurgery 21:115–116, 2021 DOI:10.1093/ons/opab124 Received, October 6, 2020. Accepted, February 22, 2021. Published Online, May 6, 2021. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opab124 OPERATIVE NEUROSURGERY VOLUME 21 | NUMBER 2 | AUGUST 2021 | 115 Downloaded from https://academic.oup.com/ons/article/21/2/E115/6271023 by guest on 14 August 2021