Update in the treatment of intracranial atherosclerotic disease

Abstract

This review highlights the recent evolution of the imaging, medical management, surgical options and endovascular therapies for symptomatic intracranial atherosclerotic disease (ICAD). Recent imaging developments including optical coherence tomography and other modalities to assess the intracranial arteries for symptomatic ICAD are reviewed, not only to diagnose ICAD but to determine if ICAD plaques have any high-risk features for treatment. Potential future developments in the treatment of ICAD are discussed, including the development of trackable drug-coated balloons for the cerebral circulation to treat primary or restenotic arteries, new iterations of self-expanding intracranial stents with easier delivery systems, and the re-examination of indirect surgical bypass techniques for revascularisation. In addition to these important technological developments, however, is the evolving evidence regarding the best treatment window for these techniques and additional factors in medical management which can improve patient outcomes in this devastating pathology.

Association of Mortality with Antiplatelet Treatment in Patients with Stent Placement or Angioplasty: A Population-Based Nested Case-Control Study

“…Unlike stent placement in the coronary artery, data regarding the effects of antiplatelet strategies after stent placement in patients with PAD or cerebral artery disease are limited. 12 38 In patients with PAD, DAPT significantly reduced re-occlusion and resulted in maintenance of target artery at 6 months after the procedure, compared to aspirin monotherapy. 10 11 It is recommended that patients who undergo procedures in the carotid artery receive DAPT (currently aspirin and clopidogrel) throughout the periprocedural period to decrease the risk of stent thrombosis/embolization; however, there is no evidencebased consensus as to how long DAPT should be continued or what kinds of antiplatelet drugs should be given.…”

“… 10 11 Meanwhile, dual antiplatelet therapy (DAPT) is recommended in intracranial cerebral artery atherosclerosis, regardless of best medical therapy or intracranial artery stent placement. 12 However, although previous randomized controlled trials provided high levels of evidence, the results do not necessarily reflect real-world outcomes, especially mortality, because only socalled stable or healthy patients are usually enrolled in randomized controlled studies. In a previous study of patients who underwent coronary stent placement, the rate of all-cause mortality was higher in patients on DAPT than those on mono-antiplatelet therapy (2.0% vs. 1.5%, respectively).…”

Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments

“… 33 34 These findings cannot be directly applied to CVS in our opinion, as CVS is caused by temporary vasoconstriction and because cerebral arteries have different properties than coronary arteries. 35 At our institution, we use CB for ERT in CVS much more often than NCB, as shown in this publication. This can be explained by the fact that our neurointerventionists often use the balloon remodelling method to treat aneurysms and are thus more familiar with the equipment and technique.…”

Outcome of Wingspan Stent Using Aggressive Post-stent Balloon Dilation for Intracranial Atherosclerosis Stenosis

“…Information of all patients who underwent wingspan stenting was retrospectively reviewed from one Medical Center between December 2018 and March 2021. The inclusion criteria for wingspan stenting included (1) ICAD with the extent of stenosis >70% using the WASID measurement method ( 15 ), (2) the stenosis lesion corresponded to the neurologic events, and (3) the interval from the final stroke or TIA to the surgery was at least 3 weeks ( 16 ). The excluding criteria included: (1) age <18 years, (2) artery stenosis combined with the non-atherosclerotic lesion, such as arteriovenous malformation and brain tumors, and (3) intolerance to antithrombotic therapy or procedure-related general anesthesia, heparinization, and contrast agents.…”