Surgical Management of Intracranial Atherosclerotic Disease

Purpose of the review Intracranial atherosclerotic disease is a complex stroke etiology with numerous challenges in its management. We present an update on the latest therapeutic research on this disease and the potential role of surgical interventions. Recent findings Despite improvements in medical therapy, intracranial atherosclerosis presents one of the highest stroke recurrences even with the best contemporary medical management. Interventions such as direct bypass, angioplasty, and stenting have failed to demonstrate superiority to medical management in well-conducted randomized clinical trials. New avenues of research are focusing on alternative interventions such as submaximal angioplasty and indirect bypass. Summary Patients with intracranial atherosclerosis should undergo intensive medical management. Angioplasty and stenting should be avoided in this population outside of well-designed clinical trials. Surgical strategies are promising but have not been tested in pivotal studies. There is an urgent need for randomized controlled clinical trials to evaluate surgical interventions like indirect bypass in patients with intracranial atherosclerosis. There is a need for early and intermediate development clinical trials for other interventions such as angioplasty without stenting or new stenting techniques.