Management of Symptomatic Intracranial Atherosclerotic Stenosis

Purpose of review This review addresses the current evidence of epidemiologic and therapeutic strategies in patients with intracranial atherosclerotic stenosis (ICAS). Recent findings There is a considerable number of patients with ICAS worldwide, especially in Asia. Modern neuroimaging techniques have improved assessment lately and they are providing insight into ICAS-related mechanisms causing cerebrovascular ischaemic events. Several studies have investigated vascular risk factors for ICAS, primarily in Asians. Vascular risk factors not only facilitate the occurrence of ICAS, but their optimal management is linked to better outcome. Antithrombotic therapies also are a crucial prevention measure in these patients. Nevertheless, under best medical therapy, a considerable recurrence rate of cerebrovascular events has been reported. Thus, it has been investigated whether endovascular therapy or surgery are safe and beneficial options in patients with ICAS. In the future, optimal best medical therapy including novel drugs and careful patient selection for interventional therapy, differentiating the underlying pathophysiological mechanism of cerebrovascular ischaemic events and identifying characteristics of ICAS will be important. Improved endovascular devices and techniques might favour better outcome as well. Current recommendations for therapeutic strategies in patients with ICAS include best medical therapy, optimal management of vascular risk factors and antithrombotic therapy. Endovascular and surgical therapy can be of benefit in selected patients.