Endovascular Treatment of Intracranial Occlusive Disease

Atherosclerosis and moyamoya disease (MMD) are the two most common forms of intracranial occlusive disease. Intracranial atherosclerotic disease (ICAD) is the leading cause of ischemic strokes in Asia and the second leading cause of stroke behind cardioembolism in the US. Medical management with antiplatelet agents and control of risk factors remains the best treatment option. Endovascular treatment has significantly evolved over the past decade. Patient selection for submaximal angioplasty and stenting has undergone intense scrutiny after the publication of negative clinical trials. Endovascular treatment of the stenotic area is recommended for patients who are symptomatic with a previous history of two or more strokes, despite best medical therapy. ICAD is also a common cause of failed acute revascularization after mechanical thrombectomy for large vessel occlusion (LVO). Poor revascularization after mechanical thrombectomy for LVO has emerged as another indication for submaximal angioplasty with or without stenting. For MMD, direct or indirect surgical bypass remains the best option, with endovascular treatment with angioplasty or stenting reserved for selected patients. Endovascular therapy for MMD is still evolving.