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Review
. 2024 Feb;55(2):344-354.
doi: 10.1161/STROKEAHA.123.043634. Epub 2024 Jan 22.

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

Theresa A Elder  1 , Timothy G White  2 , Henry H Woo  2 , Adnan H Siddiqui  3 , Ravi Nunna  4 , Farhan Siddiq  4 , Giuseppe Esposito  5 , Daniel Chang  6 , Nestor R Gonzalez  6 , Sepideh Amin-Hanjani  1
Affiliations
Review

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

Theresa A Elder et al. Stroke. 2024 Feb.

Abstract

Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.

Keywords: angioplasty; bypass; hemodynamics; ischemic stroke; risk factors; stroke.

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Conflict of interest statement

Disclosures Dr Siddiqui has the following disclosures: Financial interest/investor/stock options/ownership: Adona Medical, Inc, Bend IT Technologies Ltd, BlinkTBI, Inc, Borvo Medical, Inc, Cerebrotech Medical Systems, Inc, Code Zero Medical, Inc, Cognition Medical, Collavidence, Inc, CVAID Ltd, E8, Inc, Endostream Medical Ltd, Galaxy Therapeutics, Inc, Hyperion Surgical, Inc, Imperative Care, Inc, InspireMD Ltd, Instylla, Inc, Launch NY, Inc, Neurolutions, Inc, NeuroRadial Technologies, Inc (Sold to Medtronic in 2021), Neurovascular Diagnostics, Inc, Peijia Medical, PerFlow Medical Ltd, Piraeus Medica Inc, Q’Apel Medica, Inc, QAS.ai, Inc, Radical Catheter Technologies, Inc, Rebound Therapeutics Corp (Purchased 2019 by Integra Lifesciences), Rist Neurovascula Inc (Purchased 2020 by Medtronic), Sense Diagnostics, Inc, Serenity Medical, Inc, Silk Road Medical, Sim & Cure, Spinnaker Medical, Inc, StimMed, LLC, Synchron, Inc, Tulavi Therapeutics, Inc, Vastrax, LLC, Viseon, Inc, Whisper Medical, Inc, Willow Medtech, Inc. Consultant/advisory board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc, Boston Scientific, Canon Medical System, Inc, Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc, Cerenovus, Cordis, Corindus, Inc, Endostream Medical Ltd, Hyperfine Operations Inc, Imperative Care, InspireMD Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc, Peijia Medical, Penumbra, Piraeus Medical, Inc, Q’Apel Medical, Inc, Rapid Medical, Serenity Medical, Inc, Silk Road Medical, StimMed, LLC, Stryker Neurovascular, VasSol, vizai, Inc. National PI/Steering Committees: Cerenovus EXCELLENT (Embotrap Extraction & Clot Evaluation & Lesion Evaluation for Neurothrombectomy) and ARISE II trial (Analysis of Revascularization in Ischemic Stroke With EmboTrap); Medtronic SWIFT PRIME (Solitaire FR With the Intention for Thrombectomy as Primary Treatment for Acute Ischemic Stroke), VANTAGE, EMBOLISE (Embolization of the Middle Meningeal Artery With ONYXTM Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma), and SWIFT DIRECT (Solitaire With the Intention for Thrombectomy Plus Intravenous t-PA Versus DIRECT Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation Stroke) trials; MicroVention FRED trial (Flow Redirection Endoluminal Device trial) and CONFIDENCE study (Carotid Stent Trial to Evaluate the Safety and Efficacy of the Roadsaver Stent Used in Conjunction With the Nanoparasol Embolic Protection System for Patients at Increased Risk for Adverse Events From Carotid Endarterectomy); MUSC POSITIVE trial (Perfusion Imaging Selection of Ischemic Stroke PatIents for Endovascular Therapy); Penumbra 3D Separator trial, COMPASS trial (A Comparison of Direct Aspiration vs Stent Retriever as a First Approach), INVEST trial (Minimally Invasive Endoscopic Surgical Treatment With Apollo in Patients With Brain Hemorrhage), MIVI neuroscience EVAQ trial (Evaluate the Q Revascularization System for Neurointervention in Acute Ischemic); Rapid Medical SUCCESS trial (Success in Comaneci-Assist Coils Embolization Surveillance Study); InspireMD C-GUARDIANS IDE Pivotal trial (A Multicenter, Single-Arm, Pivotal Study to Evaluate the Safety and Efficacy of the CGuard Carotid Stent System When Used to Treat Symptomatic and Asymptomatic Carotid Artery Stenosis in Patients Undergoing Carotid Artery Stenting). Patents: Patent No. US 11,464 528 B2, Date: October 11, 2022, clot retrieval system for removing occlusive clot from a blood vessel, applicant and assignee: Neuravi Limited (Galway). Dr Esposito is a lecturer for Aesculap B. Braun and Baxter AG. Dr Gonzalez is a consultant: member of DSMB Medtronic. Grant recipient AHA. The other authors report no conflicts.