Current strategies for the treatment of intracranial atherosclerotic internal carotid artery stenosis

We evaluate the current literature regarding treatment of intracranial atherosclerotic disease, with particular emphasis on emerging medical, surgical, and endovascular trials. A MEDLINE and PubMed search of the literature related to intracranial atherosclerotic disease was performed. Articles which discussed medical, surgical, and endovascular therapies were reviewed. Currently, best medical management of intracranial atherosclerotic stenosis consists of aspirin therapy. Despite this, a significant percentage of patients with high-grade stenoses experience recurrent stroke soon after their initial event. Although previous randomized trials demonstrated no benefit to performing intracranial-extracranial bypass surgery in patients with intracranial atherosclerotic stenosis, current studies seem to suggest a benefit in a particular subset of these patients, specifically those with hemodynamic compromise. Endovascular therapy for intracranial atherosclerotic stenosis is in its infancy but is beginning to show technical promise. Nonetheless, real concerns exist regarding rates of in-stent restenosis, and large-scale follow-up studies must be completed before the true efficacy of endovascular therapies can be evaluated. Symptomatic intracranial atherosclerotic stenosis is associated with considerable morbidity and mortality. However, in a subgroup of patients, specifically those with high-grade stenoses and hemodynamic compromise, the risk of morbidity and mortality is significantly higher. It is this group of patients that would most benefit from more aggressive interventions, as best medical therapy still results in a significant rate of recurrent strokes. The emergence of improved surgical and endovascular techniques will be of particular importance in treating these high-risk patients.