The Future of Endovascular Therapy for Intracranial Atherosclerotic Disease

Editorials intracranial atherosclerosis shear stress stroke E ndovascular therapy (EVT) is a promising strategy for intracranial atherosclerotic disease (ICAD).After SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis), a landmark trial of EVT in ICAD demonstrated worse outcomes, the US Food and Drug Administration revised indications of the Wingspan stent system to more restrictive criteria. 1,2Although on-label use studies showed significantly reduced risk of periprocedural strokes, 3 the restrictive labeling means that a substantial number of patients may never qualify for this treatment, yet rates of recurrent stroke remain high in real-world data and the underlying atherogenic hemodynamic irregularities (ie, focal stenoses) remain uncorrected.EVT with stenting offers the unique possibility to "fix" the focal lesion.At the same time, EVT with stenting, angioplasty, or a combination has revealed potential in studies of acute stroke patients with large vessel occlusion (LVO) due to underlying ICAD (ICAD-LVO) and prospective studies of "rescue stenting" are ongoing. 4ow do we prove such benefit?To offset potential risks associated with stenting and balloon angioplasty, therapeutic considerations include patient-specific clinical parameters and their imaging features to identify those most at risk of having another event.If we can identify these patients, find which precision medicine