Cerebral Angioplasty and Stenting for Intracranial Atherosclerotic Disease: Current Evidence and Best Practices

Introducción

Intracranial atherosclerotic disease (ICAD) represents one of the most challenging and prevalent causes of ischemic stroke worldwide, accounting for approximately 8-10% of all strokes in Western populations and up to 30-50% in Asian populations. The pathophysiology involves progressive narrowing of the major intracranial arteries due to atherosclerotic plaque formation, leading to hypoperfusion, artery-to-artery embolism, or complete occlusion with devastating neurological consequences. Despite optimal medical management with aggressive risk factor control and antiplatelet therapy, patients with severe ICAD face a recurrent stroke risk of 12-25% within the first year after the initial event, highlighting the need for additional therapeutic strategies.

The management of ICAD has evolved significantly over the past two decades, with endovascular approaches including angioplasty and stenting emerging as potential options for selected high-risk patients. However, the field has experienced both promising advances and significant setbacks, with early enthusiasm tempered by the results of randomized controlled trials that raised concerns about periprocedural complications. As we navigate through 2025, the landscape of cerebral angioplasty and stenting continues to evolve, with refined patient selection criteria, improved device technology, and enhanced procedural techniques potentially offering safer and more effective interventions for appropriately selected patients.

This comprehensive analysis explores the current state of cerebral angioplasty and stenting for intracranial atherosclerotic disease in 2025, with particular focus on patient selection, technical considerations, clinical outcomes, and emerging evidence. From established approaches to innovative techniques, we delve into the evolving strategies that are reshaping the management of this challenging cerebrovascular condition affecting millions of individuals worldwide.

Understanding Intracranial Atherosclerotic Disease

Pathophysiology and Natural History

Before exploring specific interventional approaches, it is essential to understand the fundamental mechanisms underlying ICAD:

1. Atherosclerotic plaque development:
2. Pathological processes:
   • Endothelial dysfunction initiation
   • Lipid accumulation and oxidation
   • Inflammatory cell recruitment
   • Smooth muscle cell proliferation
   • Extracellular matrix deposition

3. Unique intracranial features:

   • Thinner adventitia than extracranial vessels
   • Fewer vasa vasorum
   • Greater elastic lamina prominence
   • Distinct hemodynamic stresses
   • Perforator-rich anatomy

4. Stroke mechanisms in ICAD:

5. Hypoperfusion:
   • Flow-limiting stenosis
   • Impaired cerebrovascular reserve
   • Watershed infarction patterns
   • Collateral circulation dependence
   • Hemodynamic vulnerability
6. Thromboembolism:
   • Plaque rupture and ulceration
   • In-situ thrombus formation
   • Artery-to-artery embolism
   • Distal territory infarction
   • Multiple embolic patterns

7. Perforator occlusion:

   • Branch ostial stenosis
   • Plaque extension over perforator origins
   • Snowplow effect from interventions
   • Lacunar infarction patterns
   • Eloquent territory vulnerability

8. Natural history and prognosis:

9. Asymptomatic disease:
   • Annual stroke risk: 3-5%
   • Progression rate: 15-20% annually
   • Risk factors for progression
   • Silent infarction prevalence
   • Cognitive impact considerations

10. Symptomatic disease:

    • Recurrent stroke risk: 12-25% in first year
    • Front-loaded risk pattern (highest early)
    • Stenosis severity correlation
    • Location-specific risks
    • Collateral circulation influence

11. Risk factors and geographic variations:

12. Traditional risk factors:
    • Hypertension (strongest association)
    • Diabetes mellitus
    • Dyslipidemia
    • Smoking
    • Advanced age
13. Ethnic variations:
    • Higher prevalence in Asian populations
    • African American predisposition
    • Hispanic intermediate risk
    • Genetic susceptibility factors
    • Environmental interactions

Diagnostic Evaluation

Enfoques integrales de evaluación:

1. Noninvasive imaging modalities:
2. Transcranial Doppler (TCD):
   • Screening capability
   • Flow velocity measurements
   • Microembolic signal detection
   • Collateral flow assessment
   • Cerebrovascular reactivity testing
3. CT angiography (CTA):
   • High spatial resolution
   • Plaque morphology visualization
   • Calcification quantification
   • Lumen measurement precision
   • Radiation exposure considerations

4. MR angiography (MRA):

   • Non-contrast time-of-flight techniques
   • Contrast-enhanced approaches
   • Vessel wall imaging capabilities
   • Plaque characterization
   • Radiation-free advantage

5. Advanced imaging techniques:

6. Vessel wall imaging:
   • High-resolution MRI protocols
   • Plaque composition assessment
   • Enhancement patterns
   • Intraplaque hemorrhage detection
   • Vulnerability markers identification
7. Perfusion studies:
   • CT perfusion
   • MR perfusion
   • SPECT
   • PET
   • Cerebrovascular reserve quantification

8. Computational fluid dynamics:

   • Wall shear stress analysis
   • Flow simulation
   • Fractional flow reserve estimation
   • Virtual intervention modeling
   • Hemodynamic impact prediction

9. Catheter angiography:

10. Gold standard assessment:
    • Highest spatial resolution
    • Dynamic flow evaluation
    • Collateral circulation assessment
    • Intervention planning capability
    • Therapeutic potential

11. Advanced techniques:

    • 3D rotational angiography
    • Flat-panel CT capabilities
    • Intravascular ultrasound integration
    • Optical coherence tomography applications
    • Pressure wire measurements

12. Functional assessment:

13. Cerebrovascular reserve testing:
    • Acetazolamide challenge
    • Breath-holding index
    • CO2 reactivity
    • BOLD fMRI applications
    • Risk stratification utility
14. Cognitive evaluation:
    • Neuropsychological testing
    • Montreal Cognitive Assessment
    • Domain-specific assessment
    • Functional impact quantification
    • Treatment decision influence

Medical Management Approaches

Standard of care before considering intervention:

1. Antiplatelet therapy:
2. Primary options:
   • Aspirin (75-325mg daily)
   • Clopidogrel (75mg daily)
   • Dual antiplatelet therapy (DAPT)
   • Cilostazol (emerging evidence)
   • Novel antiplatelet agents

3. Evidence base:

   • SAMMPRIS trial findings
   • CHANCE and POINT trial implications
   • DAPT duration considerations
   • Resistance testing utility
   • Bleeding risk balancing

4. Risk factor modification:

5. Hypertension management:
   • Target: <130/80 mmHg
   • Medication selection considerations
   • Circadian rhythm importance
   • Variability reduction strategies
   • Compliance enhancement approaches

6. Lipid management:

   • High-intensity statin therapy
   • LDL target: <70 mg/dL
   • PCSK9 inhibitor role
   • Pleiotropic effects importance
   • Plaque regression potential

7. Lifestyle modifications:

8. Dietary approaches:
   • Mediterranean diet evidence
   • DASH diet principles
   • Sodium restriction
   • Antioxidant-rich foods
   • Processed food limitation

9. Physical activity:

   • Moderate aerobic exercise
   • 150+ minutes weekly
   • Resistance training benefits
   • Supervised programs
   • Individualized prescription

10. Emerging medical therapies:

11. Anti-inflammatory approaches:
    • Colchicine evidence
    • Low-dose methotrexate trials
    • Targeted cytokine inhibition
    • NLRP3 inflammasome modulation
    • Plaque stabilization focus
12. Metabolic interventions:
    • SGLT2 inhibitors
    • GLP-1 receptor agonists
    • Insulin resistance targeting
    • Metabolic syndrome management
    • Polypharmacy considerations

Endovascular Intervention Approaches

Patient Selection for Intervention

Evidence-based approach to candidate identification:

1. Current guideline recommendations:
2. American Heart Association/American Stroke Association:
   • Medical management as first-line therapy
   • Consideration of intervention for recurrent events despite optimal medical therapy
   • Careful patient selection emphasis
   • Experienced center importance
   • Clinical trial participation encouragement

3. European Stroke Organisation:

   • Similar conservative approach
   • Medical optimization primacy
   • Highly selected intervention cases
   • Multidisciplinary decision-making
   • Registry participation recommendation

4. High-risk features for medical failure:

5. Clinical characteristics:
   • Recent symptom onset (<30 days)
   • Progressive symptoms despite therapy
   • Recurrent events on optimal medical management
   • Hemodynamic symptoms (position-dependent)
   • Poor collateral circulation

6. Imaging markers:

   • Stenosis severity (>70%)
   • Lesion length (>10mm)
   • Poor distal flow
   • Impaired cerebrovascular reserve
   • Vulnerable plaque features

7. Contraindications and cautions:

8. Anatomical challenges:
   • Excessive vessel tortuosity
   • Heavy calcification
   • Perforator-rich segments
   • Distal stenosis location
   • Tandem lesions

9. Clinical factors:

   • Recent major stroke
   • Hemorrhagic transformation
   • Significant cognitive impairment
   • Limited life expectancy
   • Inability to tolerate DAPT

10. Enfoque de equipo multidisciplinar:

11. Core team composition:
    • Vascular neurologist
    • Neurointerventionalist
    • Neurosurgeon
    • Neuroradiologist
    • Neuropsychologist
12. Decision-making framework:
    • Structured case presentation
    • Evidence-based review
    • Risk-benefit individualization
    • Patient preference incorporation
    • Normas de documentación

Angioplasty Techniques

Balloon dilation approaches:

1. Balloon angioplasty alone:
2. Consideraciones técnicas:
   • Undersizing principle (70-80% of reference vessel)
   • Slow inflation technique
   • Short balloon length selection
   • Submaximal dilation strategy
   • Staged approach for high-grade stenosis
3. Advantages:
   • Technical simplicity
   • Lower periprocedural complications
   • Preserved vessel flexibility
   • Reduced perforator compromise
   • Future treatment options preservation

4. Limitations:

   • Elastic recoil risk
   • Dissection potential
   • Restenosis rates (20-30%)
   • Suboptimal immediate result
   • Operator experience dependence

5. Drug-coated balloon angioplasty:

6. Mechanism of action:
   • Paclitaxel or sirolimus delivery
   • Anti-proliferative effect
   • Reduced neointimal hyperplasia
   • Restenosis prevention
   • Vessel patency maintenance
7. Consideraciones técnicas:
   • Predilation requirement
   • Balloon contact time importance
   • Drug delivery optimization
   • Sizing precision
   • Distal protection considerations

8. Evidence base:

   • Limited intracranial data
   • Extrapolation from coronary experience
   • Early feasibility studies
   • Registry data emergence
   • Randomized trial planning

9. Cutting/scoring balloon applications:

10. Mechanism of action:
    • Controlled plaque incision
    • Reduced barotrauma
    • Directed force application
    • Elastic recoil prevention
    • Dissection risk management
11. Consideraciones técnicas:
    • Careful sizing (1:1 ratio)
    • Lower inflation pressures
    • Microcatheter delivery challenges
    • Lesion preparation focus
    • Bailout stenting readiness

12. Specialized applications:

    • Fibrotic lesions
    • Resistant stenoses
    • Recurrent disease
    • Ostial lesions
    • Bifurcation involvement

13. Procedural considerations:

14. Access approaches:
    • Transfemoral predominance
    • Transradial emerging option
    • 6F systems standard
    • Long sheath advantages
    • Guide catheter selection
15. Adjunctive medications:
    • Periprocedural antiplatelet regimen
    • Intraprocedural anticoagulation
    • Vasodilator availability
    • Blood pressure management
    • Post-procedure antithrombotic protocol

Stenting Approaches

Permanent implant strategies:

1. Self-expanding stent systems:
2. Device characteristics:
   • Wingspan system (Stryker)
   • Enterprise system (Cerenovus)
   • Neuroform Atlas (Stryker)
   • Low radial force profile
   • High conformability
3. Consideraciones técnicas:
   • Predilation requirement
   • Sizing (oversizing by 0.5-1.0mm)
   • Deployment precision
   • Foreshortening management
   • Post-dilation considerations

4. Advantages/limitations:

   • Conformability to tortuous anatomy
   • Lower vessel straightening
   • Potential for delayed expansion
   • Sizing challenges
   • Deployment accuracy demands

5. Balloon-expandable stent applications:

6. Device options:
   • Coronary stents (off-label)
   • Specific neurovascular designs
   • Drug-eluting capabilities
   • Cobalt-chromium platforms
   • Delivery system limitations
7. Consideraciones técnicas:
   • Precise sizing (1:1 ratio)
   • Single-step deployment
   • Higher radial force
   • Vessel straightening potential
   • Delivery challenges in tortuosity

8. Specialized applications:

   • Short, focal lesions
   • Proximal locations
   • Less tortuous segments
   • Ostial disease
   • Resistant stenoses

9. Drug-eluting stent considerations:

10. Mechanism of action:
    • Controlled drug release
    • Anti-proliferative effects
    • Restenosis reduction
    • Neointimal hyperplasia inhibition
    • Sustained vessel patency
11. Evidence base:
    • Limited intracranial-specific data
    • Coronary experience extrapolation
    • Case series and registries
    • Promising preliminary results
    • Randomized trial needs

12. Technical adaptations:

    • Delivery system limitations
    • Navigation challenges
    • Deployment precision
    • DAPT duration implications
    • Follow-up protocol modifications

13. Covered stent applications:

14. Specialized indications:
    • Dissection complications
    • Perforation management
    • Pseudoaneurysm exclusion
    • Vessel rupture treatment
    • Bailout scenarios
15. Consideraciones técnicas:
    • Limited flexibility
    • Perforator occlusion risk
    • Delivery system profile
    • Sizing precision
    • Landing zone requirements
16. Available systems:
    • Graftmaster (Abbott)
    • PK Papyrus (Biotronik)
    • BeGraft (Bentley)
    • Navigation limitations
    • Profile considerations

Novel and Emerging Approaches

Innovative strategies under investigation:

1. Temporary endovascular bypass:
2. Concept and mechanism:
   • Flow reversal during intervention
   • Distal protection enhancement
   • Collateral augmentation
   • Ischemic protection
   • Hemodynamic support

3. Technical approaches:

   • Balloon occlusion techniques
   • Specialized flow reversal systems
   • Partial flow support
   • Pressure monitoring integration
   • Physiological endpoints

4. Intravascular lithotripsy:

5. Mechanism of action:
   • Sonic pressure wave delivery
   • Calcium disruption
   • Plaque modification
   • Reduced barotrauma
   • Vessel compliance improvement
6. Consideraciones técnicas:
   • Specialized balloon catheter
   • Energy delivery parameters
   • Sizing principles
   • Delivery system navigation
   • Adjunctive treatment integration

7. Early experience:

   • Feasibility demonstrations
   • Heavily calcified lesion focus
   • Coronary experience translation
   • Safety profile emergence
   • Efficacy assessment needs

8. Bioabsorbable stent technologies:

9. Platform characteristics:
   • Poly-L-lactic acid scaffolds
   • Magnesium alloy designs
   • Bioresorbable timeframes
   • Radial support duration
   • Drug-elution capabilities
10. Potential advantages:
    • Temporary scaffolding
    • Late lumen enlargement
    • Vessel physiology restoration
    • Future retreatment facilitation
    • Reduced late thrombosis

11. Development challenges:

    • Strut thickness limitations
    • Deliverability constraints
    • Radiopacity challenges
    • Resorption unpredictability
    • Early failure concerns

12. Robotic-assisted intervention:

13. System capabilities:
    • Remote catheter manipulation
    • Enhanced stability
    • Precision movements
    • Reduced radiation exposure
    • Reducción de la fatiga del operador
14. Consideraciones técnicas:
    • Learning curve
    • Setup requirements
    • Tactile feedback limitations
    • Workflow integration
    • Cost implications
15. Early applications:
    • Complex anatomy navigation
    • Stable catheter positioning
    • Precise measurements
    • Reduced contrast requirements
    • Standardized movements

Resultados clínicos y pruebas

Randomized Controlled Trials

Landmark studies shaping current practice:

1. SAMMPRIS trial (2011):
2. Study design:
   • 451 patients with 70-99% stenosis
   • Recent TIA or stroke within 30 days
   • Randomized to aggressive medical management vs. Wingspan stenting
   • Primary endpoint: stroke or death within 30 days or stroke in territory beyond 30 days
   • Early termination for safety concerns
3. Key findings:
   • 30-day stroke/death: 14.7% stenting vs. 5.8% medical
   • 1-year primary endpoint: 20.0% stenting vs. 12.2% medical
   • Periprocedural complications higher than expected
   • Aggressive medical therapy more effective than anticipated
   • Subgroup analyses failed to identify clear benefiting populations

4. Impact on practice:

   • Paradigm shift toward medical management primacy
   • Restricted stenting indications
   • Enhanced medical therapy protocols
   • Procedural risk recognition
   • Perfeccionamiento de la selección de pacientes

5. VISSIT trial (2015):

6. Study design:
   • 112 patients with symptomatic 70-99% stenosis
   • Balloon-expandable stent vs. medical therapy
   • Similar inclusion criteria to SAMMPRIS
   • Primary endpoint: stroke or TIA in same territory
   • Early termination after SAMMPRIS results
7. Key findings:
   • Higher 30-day stroke rate with stenting (24.1% vs. 9.4%)
   • 1-year primary endpoint: 36.2% stenting vs. 15.1% medical
   • Consistent with SAMMPRIS findings
   • Different stent platform, similar outcomes
   • Reinforced medical management preference

8. Impact on practice:

   • Further restriction of intervention indications
   • Balloon-expandable stent cautions
   • Strengthened medical therapy emphasis
   • Research focus redirection
   • Guideline reinforcement

9. WEAVE trial (2019):

10. Study design:
    • 152 on-label Wingspan stent patients
    • Prospective, single-arm registry
    • Strict adherence to FDA humanitarian device exemption criteria
    • Primary endpoint: 30-day stroke or death
    • Focus on procedural outcomes
11. Key findings:
    • 30-day stroke/death rate: 2.6%
    • Substantially lower than SAMMPRIS (14.7%)
    • Strict patient selection importance
    • Operator experience significance
    • Technical protocol adherence value

12. Impact on practice:

    • Refined patient selection criteria
    • Operator experience emphasis
    • Protocol standardization importance
    • Renewed consideration for selected cases
    • Registry data value recognition

13. Ongoing and recent trials:

14. CASSISS trial (China):
    • Completed enrollment of 380 patients
    • Wingspan stenting vs. medical therapy
    • More stringent patient selection
    • Experienced operators
    • Results pending full publication
15. MACROSS registry:
    • Multicenter assessment of current practice
    • Real-world outcomes documentation
    • Focus on contemporary techniques
    • Patient selection patterns
    • Complication management strategies

Registry and Real-World Data

Evidence beyond randomized trials:

1. Post-SAMMPRIS registries:
2. NIH Wingspan registry:
   • 158 patients with high-risk features
   • 30-day stroke/death: 2.5%
   • 1-year stroke in territory: 8.5%
   • Perfeccionamiento de la selección de pacientes
   • Technical improvements
3. Chinese multicenter experience:
   • Over 300 patients
   • Periprocedural complication rate: 4.3%
   • Restenosis rate: 25.9% at median 7 months
   • Symptomatic restenosis: 7.2%
   • Technical success: 96.7%

4. European registry data:

   • Heterogeneous approaches
   • Balloon angioplasty preference in some centers
   • Stenting reserved for suboptimal results
   • Complication rates: 4-7%
   • Restenosis concerns

5. Angioplasty-focused experiences:

6. Submaximal angioplasty technique:
   • 120 patients across multiple centers
   • Technical success: 91.7%
   • 30-day stroke/death: 5.0%
   • Restenosis requiring retreatment: 14.2%
   • Stent avoidance in 87.5%

7. Gateway balloon system registry:

   • 131 patients with symptomatic ICAD
   • Angioplasty alone: 52%
   • Bailout stenting: 48%
   • Periprocedural complications: 5.3%
   • Restenosis rates: 24% angioplasty vs. 12% stenting

8. Drug-eluting technology experiences:

9. Drug-eluting stent case series:
   • 95 patients across 3 centers
   • Technical success: 100%
   • 30-day stroke/death: 4.2%
   • Restenosis rate: 7.5% at mean 14 months
   • Target lesion revascularization: 5.3%

10. Drug-coated balloon preliminary data:

    • 42 patients in single-center experience
    • Technical success: 95.2%
    • 30-day stroke/death: 4.8%
    • 6-month restenosis: 9.5%
    • Promising early results

11. Special population experiences:

12. Vertebrobasilar disease focus:
    • Higher risk location historically
    • Contemporary series: 6-8% complication rates
    • Basilar apex access challenges
    • Perforator-rich territory concerns
    • Modified techniques for safety
13. Tandem lesion management:
    • Combined extracranial-intracranial disease
    • Staged vs. simultaneous approaches
    • Proximal-to-distal strategy preference
    • Embolic protection considerations
    • 30-day event rates: 7-10%

Predictors of Outcomes

Factors influencing success and complications:

1. Patient-related factors:
2. Demographic influences:
   • Age impact (>70 years higher risk)
   • Gender differences (minimal)
   • Ethnic variations in response
   • Comorbidity burden significance
   • Prior stroke impact

3. Lesion characteristics:

   • Stenosis severity (>90% higher risk)
   • Lesion length (>10mm challenging)
   • Plaque morphology influence
   • Calcification burden
   • Perforator involvement

4. Procedural factors:

5. Technical approaches:
   • Balloon sizing impact
   • Inflation strategy influence
   • Stent selection considerations
   • Embolic protection value
   • Access route selection

6. Operator experience:

   • Relación volumen-resultado
   • Learning curve effects
   • Technical skill variation
   • Complication management capability
   • Decision-making experience

7. Periprocedural management:

8. Antithrombotic regimens:
   • DAPT loading timing
   • Intraprocedural anticoagulation
   • Post-procedure DAPT duration
   • Resistance testing utility
   • Novel agent considerations

9. Hemodynamic management:

   • Blood pressure control importance
   • Hyperperfusion risk mitigation
   • Bradycardia management
   • Vasopressor avoidance
   • Fluid management strategy

10. Post-procedure care:

11. Monitoring protocols:
    • Neurological assessment frequency
    • Blood pressure parameters
    • Imaging surveillance timing
    • Symptom recognition education
    • Duration of intensive observation
12. Long-term management:
    • DAPT duration optimization
    • Risk factor control intensity
    • Restenosis surveillance
    • Activity guidance
    • Secondary prevention adherence

Gestión de complicaciones

Strategies for addressing adverse events:

1. Ischemic complications:
2. Acute vessel occlusion:
   • Immediate recognition
   • Rescue strategies (thrombolysis, thrombectomy)
   • Underlying cause determination
   • Anticoagulation adjustment
   • Hemodynamic optimization

3. Distal embolization:

   • Clinical detection
   • Imaging confirmation
   • Mechanical thrombectomy consideration
   • Thrombolytic options
   • Supportive management

4. Hemorrhagic complications:

5. Vessel perforation:
   • Balloon tamponade
   • Anticoagulation reversal
   • Covered stent consideration
   • Sacrifice evaluation if needed
   • Blood pressure control

6. Reperfusion injury:

   • Prevention through staged dilation
   • Blood pressure strict control
   • Symptom recognition
   • Imaging confirmation
   • Medical management vs. decompression

7. Technical complications:

8. Dissection management:
   • Flow-limiting vs. non-flow-limiting
   • Stenting indications
   • Conservative management options
   • Follow-up imaging protocols
   • Antithrombotic adjustments

9. Device failure:

   • Balloon rupture management
   • Stent deployment failure
   • Retrieval techniques
   • Bailout strategies
   • Procedure abandonment criteria

10. Delayed complications:

11. In-stent restenosis:
    • Surveillance protocols
    • Symptomatic vs. asymptomatic management
    • Repeat angioplasty approach
    • Drug-eluting technology role
    • Optimización de la terapia médica
12. Delayed thrombosis:
    • Risk factor identification
    • DAPT compliance emphasis
    • Acute management approaches
    • Secondary prevention intensification
    • Monitoring protocol adjustment

Orientaciones futuras

Looking beyond 2025, several promising approaches may further refine cerebral angioplasty and stenting:

1. Technological innovations:
2. Next-generation devices:
   • Lower profile delivery systems
   • Enhanced flexibility
   • Improved radial force distribution
   • Better conformability
   • Reduced thrombogenicity

3. Imaging integration:

   • Intraprocedural OCT/IVUS guidance
   • Real-time computational fluid dynamics
   • Visualización de realidad aumentada
   • Automated stenosis quantification
   • Plaque characterization capabilities

4. Pharmacological advances:

5. Novel antithrombotics:
   • Targeted platelet inhibition
   • Reduced bleeding risk profiles
   • Intravenous bridging options
   • Reversibility features
   • Individualized therapy selection

6. Local drug delivery:

   • Sustained-release technologies
   • Nanoparticle applications
   • Targeted anti-inflammatory agents
   • Endothelial healing promotion
   • Restenosis prevention focus

7. Procedural refinements:

8. Neuroprotection strategies:
   • Distal protection device improvements
   • Flow reversal techniques
   • Pharmacological neuroprotection
   • Collateral enhancement approaches
   • Staged intervention protocols

9. Access innovations:

   • Transradial technique optimization
   • Distal radial approaches
   • Reduced access site complications
   • Lower profile systems
   • Enhanced guide support

10. Clinical evidence development:

11. Refined trial designs:
    • Better patient selection criteria
    • Physiological assessment integration
    • Longer-term follow-up
    • Quality of life endpoints
    • Cost-effectiveness evaluation
12. Personalized approach validation:
    • Predictive modeling
    • Risk score development
    • Imaging-based selection
    • Genetic marker integration
    • Treatment response prediction

Descargo de responsabilidad médica

This article is intended for informational purposes only and does not constitute medical advice. The information provided regarding cerebral angioplasty and stenting for intracranial atherosclerotic disease is based on current research and clinical evidence as of 2025 but may not reflect all individual variations in treatment responses. The determination of appropriate treatment approaches should be made by qualified healthcare professionals based on individual patient characteristics, anatomical considerations, and specific clinical scenarios. Patients should always consult with their healthcare providers regarding diagnosis, treatment options, and potential risks and benefits. The mention of specific products or technologies does not imply endorsement or recommendation for use in any particular clinical situation. Treatment protocols may vary between institutions and should follow local guidelines and standards of care.

Conclusión

The management of intracranial atherosclerotic disease remains one of the most challenging areas in cerebrovascular medicine, with endovascular intervention representing a potentially valuable option for carefully selected patients who have failed optimal medical therapy. The landscape has evolved significantly since the sobering results of the SAMMPRIS and VISSIT trials, with refined patient selection, improved devices, and enhanced procedural techniques potentially offering safer and more effective interventions.

As we navigate through 2025, the pendulum appears to be swinging toward a more balanced approach, recognizing both the primacy of aggressive medical management and the potential role of intervention in specific high-risk scenarios. The accumulating evidence from registries and real-world experience suggests that with appropriate patient selection, contemporary techniques, and experienced operators, the procedural risks may be substantially lower than observed in earlier randomized trials.

Looking forward, continued innovation in device design, procedural techniques, and pharmacological approaches promises to further refine cerebral angioplasty and stenting, potentially expanding its application to a broader range of patients with this challenging cerebrovascular condition. The ideal of providing durable protection against recurrent stroke while minimizing procedural risks remains the goal driving this field forward. By applying the principles outlined in this analysis, clinicians can navigate the complex landscape of ICAD management to optimize outcomes for individual patients.

References

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