Does neuroendovascular surgery treat intracranial atherosclerosis disease and stenosis of the left Internal Carotid Artery (ICA)?

Neuroendovascular Treatment of Intracranial Atherosclerosis and ICA Stenosis

Yes, neuroendovascular surgery does treat intracranial atherosclerotic disease and stenosis of the left internal carotid artery (ICA), but only in highly selected symptomatic patients who have failed aggressive medical management, and procedures should be performed exclusively at high-volume academic centers with significant neurovascular expertise. 1

Primary Treatment Approach

Aggressive medical management is the first-line treatment for symptomatic intracranial atherosclerotic stenosis, not endovascular intervention. 1 The standard medical regimen includes:

• Dual antiplatelet therapy with clopidogrel 75 mg plus aspirin 75-81 mg daily for 21-30 days, followed by single antiplatelet agent (aspirin or clopidogrel alone) 1
• Loading dose of aspirin 160 mg immediately after brain imaging excludes hemorrhage 1
• Aggressive risk factor management including control of hypertension, hyperlipidemia, and diabetes 2

Endovascular Intervention Indications

Neuroendovascular procedures (angioplasty and stenting) are reserved for highly selected patients only with the following criteria 1:

• Symptomatic stenosis ≥50% that is refractory to medical therapy 1
• Documented failure of adequate medical management 2
• Timing considerations: Generally performed at least 7 days after ischemic stroke, as patients treated in the acute phase have higher procedure-related complications 2

Available Endovascular Techniques

The neuroendovascular armamentarium includes 2:

• Balloon angioplasty alone
• Balloon-mounted stents
• Self-expanding stent systems (e.g., Wingspan stent system with FDA humanitarian device exemption) 1

Critical Risk-Benefit Considerations

The risks of endovascular intervention are substantial and must be carefully weighed:

Procedural Risks

• 14% rate of stroke, hemorrhage, or death at 30 days or ipsilateral stroke at 6 months 1
• Periinterventional rates: 7.9% stroke, 3.4% death, and 9.5% combined stroke or death 2
• Compared to medical management alone, endovascular therapy plus medical treatment increases short-term death or stroke risk (RR 2.93) 3
• Hemorrhagic stroke risk is significantly elevated (RR 13.49 short-term) 3

High-Risk Patient Characteristics

• Severe stenosis ≥70% carries the highest stroke risk (hazard ratio 2.00) in the territory of the stenotic artery 1, 2
• Early presentation (≤17 days after qualifying event) has higher stroke risk (hazard ratio 1.72) 1, 2

Institutional and Operator Requirements

Endovascular procedures for intracranial atherosclerosis should only be performed at:

• High-volume academic medical centers with significant neurovascular expertise 1, 2
• Centers with experienced multidisciplinary teams including vascular neurologists, neuroendovascular specialists, neuroanesthesiologists, and neurointensivists 2, 4
• The procedure is technically demanding at many levels and carries substantial risk 2

Diagnostic Workup

MRI with MRA is the recommended initial diagnostic test for suspected arteriopathy 1. For patients with diffuse intracranial stenosis, consider alternative diagnoses including:

• Moyamoya disease/syndrome
• Primary CNS vasculitis
• Connective tissue disorders
• Radiation-induced arteriopathy 1

Common Pitfalls to Avoid

• Do not proceed with endovascular intervention without documented failure of aggressive medical management 2, 1
• Avoid intervention in asymptomatic patients - there is currently insufficient evidence to recommend endovascular treatment for asymptomatic intracranial stenosis 2
• Do not perform procedures at low-volume centers or by inexperienced operators, as outcomes are operator and institution-dependent 1, 2
• Avoid early intervention (within 7 days of acute stroke) due to higher complication rates 2

Current Evidence Limitations

The value of endovascular treatment has been demonstrated primarily in case series rather than well-designed randomized controlled trials 2. Major trials (SAMMPRIS and VISSIT) showed that medical management alone was superior to endovascular treatment, though these trials have been criticized for patient selection, intervention timing, and operator experience factors 4, 3.