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Updated: May 26, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Current diagnosis and management of symptomatic intracranial atherosclerotic disease
Shyam Prabhakaran1, Jose G Romano
1Rush University Medical Center, Chicago, Illinois, USA.
Insights
Intracranial atherosclerotic disease (IAD) is a leading cause of stroke. Aggressive medical management is recommended, with caution advised for endovascular treatments, to reduce stroke recurrence risk.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Radiology
Background:
- Intracranial atherosclerotic disease (IAD) is a primary global cause of stroke.
- IAD leads to cerebral ischemia via embolism, hemodynamic failure, or penetrating artery occlusion.
- High recurrence rates underscore the need for advanced understanding and treatment.
Purpose of the Study:
- To review traditional and novel imaging modalities for IAD.
- To discuss recent therapeutic trial findings for IAD.
- To explore how physiological insights can refine IAD patient risk assessment and therapy.
Main Methods:
- Review of traditional imaging techniques (e.g., angiography, MRI, CT) and their limitations.
- Discussion of novel physiological imaging approaches to elucidate ischemia mechanisms.
- Analysis of recent clinical trials, including antiplatelet therapy, risk factor modification, and endovascular interventions.
Main Results:
- Traditional imaging offers anatomical insights but limited physiological data.
- Novel physiological imaging enhances understanding of IAD-related ischemia mechanisms.
- Recent trials support antiplatelet agents and risk factor modification; endovascular approaches carry significant complication risks.
Conclusions:
- Aggressive medical management is currently favored for IAD.
- Caution is advised regarding interventional treatments due to potential complications.
- Mechanistic information from advanced imaging can guide targeted IAD therapies and improve risk stratification.
Purpose Of Review:
Intracranial atherosclerotic disease (IAD) is likely the most common cause of stroke world-wide and is associated with a very high risk of recurrence. It results in cerebral ischemia due to a variety of mechanisms, including artery-to-artery embolism, hemodynamic failure, and occlusion of penetrating arteries. New imaging modalities focused on physiological consequences of IAD have become available and recent treatment trials have been completed.
Recent Findings:
We review the traditional imaging modalities, emphasizing the advantages and limitations of each method, and discuss the novel physiological approaches that interrogate physiological process to indicate specific mechanisms of ischemia. These allow deeper understanding of the pathophysiological processes that underlie IAD-related ischemia. The key findings of recent therapeutic trials are reviewed, including the landmark randomized studies showing advantage of antiplatelet agents and risk factor modification, and a significant risk of complications with endovascular approaches.
Summary:
Current evidence argues for aggressive medical management and suggests caution with interventional treatments. We propose that mechanistic information will further refine the risk assessment of patients with IAD to offer targeted therapy.
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