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Standard of practice: endovascular treatment of intracranial atherosclerosis
  1. M Shazam Hussain1,
  2. Justin F Fraser2,
  3. Todd Abruzzo3,
  4. Kristine A Blackham4,
  5. Ketan R Bulsara5,
  6. Colin P Derdeyn6,
  7. Chirag D Gandhi7,
  8. Joshua A Hirsch8,
  9. Daniel P Hsu9,
  10. Mahesh V Jayaraman10,
  11. Philip M Meyers11,
  12. Sandra Narayanan12,
  13. Charles J Prestigiacomo13,
  14. Peter A Rasmussen1 On behalf of the Society for NeuroInterventional Surgery
  1. 1Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  3. 3Neurosurgery, Radiology, Pediatrics and Biomedical Engineering, University of Cincinnati, Mayfield Clinic and Cincinnati Children's Hospital, Cincinnati, Ohio
  4. 4Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
  5. 5Yale Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  6. 6Washington University School of Medicine/Barnes Jewish Hospital, St Louis, Missouri, USA
  7. 7Neurological Institute of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
  8. 8Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  9. 9Division of Interventional Neuroradiology, University Hospitals – Case Medical Center, Cleveland, Ohio, USA
  10. 10Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
  11. 11Department of Radiology and Neurological Surgery, Columbia University, College of Physicians and Surgeons, and Neuroendovascular Service, New York Presbyterian-Columbia, Neurological Institute of New York, New York, USA
  12. 12Departments of Neurosurgery and Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
  13. 13Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  1. Correspondence to Dr M S Hussain, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Ave, S80, Cleveland, Ohio 44195, USA; hussais4{at}


Background Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD.

Methods A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM).

Results 59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4.

Conclusion Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.

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  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.