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

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Abstract

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.

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Acknowledgement

The figures of the Wingspan stent were obtained from Boston Scientific and submitted with their permission.

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Correspondence to Ketan R. Bulsara.

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Claudius Thomé, Mannheim, Germany

Drs. Patel and Bulsara provide an up-to-date review on the current treatment options for intracranial atherosclerotic stenosis and touch possible future developments. The authors are to be congratulated on their endeavor to shed light on this important but often neglected topic. While indications and treatment options have been vigorously studied for extracranial atherosclerotic disease, data on intracranial atherosclerotic stenosis are scarce. Nevertheless, it is a major cause of ischemic events, and particularly high-grade intracranial stenosis carries a rather poor prognosis.

Recently, the WASID study established aspirin as the optimal medical therapy, which undoubtedly represents the best management for the majority of affected patients. However, the authors correctly identify a subset of patients, which are likely to benefit from more invasive treatment—those with high-grade stenosis and cerebrovascular hemodynamic insufficiency. We will have to await the results of the described JET and COSS studies to assess the suggested value of EC–IC bypass surgery. New microsurgical techniques like ICG videoangiography are mentioned, which may reduce surgical morbidity. The described ELANA technique has been added to the neurosurgical armamentarium and is particularly useful to detour the blood flow around large skull-base aneurysms. In my personal opinion, this technique is only rarely indicated in atherosclerotic disease, where STA–MCA anastomosis will remain the workhorse of EC–IC bypass surgery.

Endovascular treatment options including problems and future potentials are adequately addressed in this review. While early interventions were associated with unacceptable morbidity, new developments are promising. Nevertheless, restenosis and ongoing difficulties with drug-eluting stents have to be kept in mind prior to wide-spread acceptance of these techniques. A treatment benefit over medical therapy must first be demonstrated in adequately designed studies. Meticulous attention must also be paid to the indications of endovascular therapy, as poor patient selection may reproduce the devastating results of the international extracranial–intracranial bypass trial in the 1980s.

Hopefully, upcoming data on bypass surgery and interventional techniques will provide us with paradigms on how to treat our patients with intracranial atherosclerotic stenosis. While clinical decision making in everyday practice should be based on well-defined criteria, invasive treatment should be concentrated in specialized centers.

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Patel, T.R., Bulsara, K.R. Current strategies for the treatment of intracranial atherosclerotic internal carotid artery stenosis. Neurosurg Rev 32, 23–28 (2009). https://doi.org/10.1007/s10143-008-0172-2

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  • DOI: https://doi.org/10.1007/s10143-008-0172-2

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