Endovascular Treatment of Intracranial Atherosclerosis

Intracranial atherosclerosis is a leading cause of ischaemic stroke worldwide, characterised by plaque formation and luminal narrowing within the cerebral arteries. Endovascular treatment (EVT) has emerged as a vital approach to restore perfusion in cases of acute large vessel occlusion (LVO) due to intracranial atherosclerotic stenosis or occlusive plaque rupture. Techniques include mechanical thrombectomy with stent retrievers or contact aspiration, balloon angioplasty with or without stent placement, and local infusion of antiplatelet agents. While rapid recanalisation correlates strongly with improved neurological outcome, procedures may be prolonged by underlying stenosis, re-occlusion and vessel injury. Successful management demands prompt identification of atherosclerotic aetiology, selection of frontline devices, and readiness to deploy bespoke rescue strategies such as angioplasty, permanent stenting or glycoprotein IIb/IIIa inhibitors. Globally, intracranial atherosclerosis disproportionately affects populations in Asia, Africa and Hispanic communities, underlining the need for adaptable endovascular protocols that can be implemented across diverse healthcare settings.

Research from Nature Portfolio

Recent studies have refined pre-procedural prediction of intracranial atherosclerotic LVO. A 2024 cross-sectional analysis of over 300 stroke patients treated with EVT demonstrated that absence of atrial fibrillation, a lower hypoperfusion intensity ratio, evidence of intracranial artery calcification on imaging, more proximal occlusion location and a history of smoking reliably distinguish atherosclerotic occlusions from embolic ones. Incorporating these five variables into a logistic regression model yielded excellent discrimination (area under the curve 0.88), suggesting that a simple clinico-radiological score can guide operators towards a tailored endovascular strategy and anticipate the need for angioplasty or stenting.

Endovascular Treatment of Intracranial Atherosclerosis publication trend

The graph below shows the total number of articles in endovascular treatment of intracranial atherosclerosis across all publications each year (not limited to Nature Index journals).

Technical terms

Intracranial atherosclerosis: Plaque build-up within the cerebral arteries leading to stenosis or occlusion.

Large vessel occlusion (LVO): Complete or severe blockage of a major intracranial artery causing acute ischaemic stroke.

Mechanical thrombectomy: Endovascular removal of a clot using stent retrievers or aspiration catheters.

Balloon angioplasty: Inflation of a balloon within a stenosed vessel to widen the lumen.

Stent retriever: A self-expanding device deployed across a thrombus to capture and remove it.

Contact aspiration: Suction-based thrombectomy using a distal aspiration catheter.

Glycoprotein IIb/IIIa inhibitor: Potent antiplatelet medication infused locally to prevent re-occlusion.

References

1. Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment. Scientific Reports (2024).
2. Local tirofiban infusion for remnant stenosis in large vessel occlusion: tirofiban ASSIST study. BMC Neurology (2020).
3. Immediate effects of first-line thrombectomy devices for intracranial atherosclerosis-related occlusion: stent retriever versus contact aspiration. BMC Neurology (2020).
4. Endovascular and Clinical Outcomes of Vertebrobasilar Intracranial Atherosclerosis-Related Large Vessel Occlusion. Frontiers in Neurology (2019).