Endovascular Therapy in Intracranial Atherosclerotic Stenosis-Related Large Vessel Occlusion Stroke: A Brief Practice Update and Consensus Statement From the SVIN
18 affiliations
- 1Department of Neurosurgery (S.A.K., A.M.S.), Medical University of South Carolina, Charleston.
- 2Department of Neurology (A.A.Q.), Medical University of South Carolina, Charleston.
- 3Department of Neurology, Hackensack Meridian Neuroscience Institute, NJ (S.Y.).
- 4Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa (W.R.G.).
- 5Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (S.M.).
- 6Department of Radiology (M.A.), Boston University School of Medicine, MA.
- 7Department of Neurology, Indiana University School of Medicine, Indianapolis (K.L.).
- 8Department of Neurology, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z., A.C.).
- 9Department of Neurology, Yale School of Medicine, New Haven, CT (A.d.H.).
- 10Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles (D.S.L.).
- 11Department of Neurology, The University of Chicago, IL (T.K.-H.).
- 12Department of Neurosurgery, University of Missouri Health Care, Columbia (F.S.).
- 13Department of Neurology, UPMC Altoona and University of Pittsburgh School of Medicine, PA (C.L.K.).
- 14Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Valley Baptist Medical Center, Harlingen (A.E.H.).
- 15Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (A.L.C.).
- 16Department of Neurology, University of Iowa Hospitals and Clinics, Iowa (E.A.S.).
- 17Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (M.A.J.).
- 18Department of Neurology (T.N.N.), Boston University School of Medicine, MA.
Abstract
Intracranial atherosclerotic stenosis-related large vessel occlusion (ICAS-LVO) represents a distinct subset of acute ischemic stroke with unique diagnostic and therapeutic challenges during endovascular therapy. Compared with embolic LVO, ICAS-LVO is associated with higher rates of reocclusion and the frequent use of adjunctive interventions. This Brief Practice Update summarizes current evidence and expert consensus to guide the identification and management of ICAS-LVO during endovascular therapy. The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee convened a multidisciplinary writing group of neurointerventionalists to review available literature and define key clinical questions on ICAS-LVO and endovascular therapy. Evidence was appraised using the Society of Vascular and Interventional Neurology framework for Class of Recommendation and Level of Evidence, adapted from the American College of Cardiology/American Heart Association. Draft statements were iteratively refined and approved by the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Quality Committee for adherence to internal standards and endorsed by the Society of Vascular and Interventional Neurology Board of Directors. Evidence was derived from randomized trials, multicenter registries, cohort studies, post hoc analyses, and meta-analyses addressing diagnostic features, first-line thrombectomy strategies, and adjunctive therapies in ICAS-LVO. Both stent retriever and direct aspiration approaches are acceptable initial strategies; however, durable recanalization is only achieved in about half of patients. Adjunctive use of intravenous or intra-arterial glycoprotein IIb/IIIa inhibitors, balloon angioplasty, and rescue stenting has demonstrated improved recanalization rates and favorable functional outcomes in observational studies, without increased hemorrhagic complications. However, the quality of evidence remains weak. A summary of recommendations is provided to guide practice in common procedural scenarios. This Brief Practice Update provides evidence-based and expert consensus recommendations for the diagnosis and endovascular treatment of ICAS-LVO. Management should be individualized by incorporating the clinical presentation, imaging characteristics, and operator expertise. While adjunctive therapy may be beneficial in select cases, high-quality randomized trials are needed to define optimal strategies and establish standardized algorithms for this challenging stroke subtype.
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BibTeX
@article{kasab2026endovascular,
title = {{Endovascular Therapy in Intracranial Atherosclerotic Stenosis-Related Large Vessel Occlusion Stroke: A Brief Practice Update and Consensus Statement From the SVIN}},
author = {Sami Al Kasab and Ahmad Abu Qdais and Shadi Yaghi and Waldo R Guerrero and Shahram Majidi and Mohamad Abdalkader and Kaustubh Limaye and Osama O Zaidat and Adam de Havenon and David S Liebeskind and Amit Chaudhari and Tareq Kass-Hout and Farhan Siddiq and Cynthia L Kenmuir and Ameer E Hassan and Alejandro M Spiotta and Alexandra L Czap and Edgar A Samaniego and Mouhammad Jumaa and Thanh N Nguyen},
journal = {Stroke (Hoboken, N.J.)},
year = {2026},
month = nov,
doi = {10.1161/svin.126.002529},
url = {https://europepmc.org/article/PMC/PMC13727248},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - Endovascular Therapy in Intracranial Atherosclerotic Stenosis-Related Large Vessel Occlusion Stroke: A Brief Practice Update and Consensus Statement From the SVIN
AU - Sami Al Kasab
AU - Ahmad Abu Qdais
AU - Shadi Yaghi
AU - Waldo R Guerrero
AU - Shahram Majidi
AU - Mohamad Abdalkader
AU - Kaustubh Limaye
AU - Osama O Zaidat
AU - Adam de Havenon
AU - David S Liebeskind
AU - Amit Chaudhari
AU - Tareq Kass-Hout
AU - Farhan Siddiq
AU - Cynthia L Kenmuir
AU - Ameer E Hassan
AU - Alejandro M Spiotta
AU - Alexandra L Czap
AU - Edgar A Samaniego
AU - Mouhammad Jumaa
AU - Thanh N Nguyen
PY - 2026
DA - 2026/11/01
JO - Stroke (Hoboken, N.J.)
DO - 10.1161/svin.126.002529
UR - https://europepmc.org/article/PMC/PMC13727248
AB - Intracranial atherosclerotic stenosis-related large vessel occlusion (ICAS-LVO) represents a distinct subset of acute ischemic stroke with unique diagnostic and therapeutic challenges during endovascular therapy. Compared with embolic LVO, ICAS-LVO is associated with higher rates of reocclusion and the frequent use of adjunctive interventions. This Brief Practice Update summarizes current evidence and expert consensus to guide the identification and management of ICAS-LVO during endovascular therapy. The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee convened a multidisciplinary writing group of neurointerventionalists to review available literature and define key clinical questions on ICAS-LVO and endovascular therapy. Evidence was appraised using the Society of Vascular and Interventional Neurology framework for Class of Recommendation and Level of Evidence, adapted from the American College of Cardiology/American Heart Association. Draft statements were iteratively refined and approved by the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Quality Committee for adherence to internal standards and endorsed by the Society of Vascular and Interventional Neurology Board of Directors. Evidence was derived from randomized trials, multicenter registries, cohort studies, post hoc analyses, and meta-analyses addressing diagnostic features, first-line thrombectomy strategies, and adjunctive therapies in ICAS-LVO. Both stent retriever and direct aspiration approaches are acceptable initial strategies; however, durable recanalization is only achieved in about half of patients. Adjunctive use of intravenous or intra-arterial glycoprotein IIb/IIIa inhibitors, balloon angioplasty, and rescue stenting has demonstrated improved recanalization rates and favorable functional outcomes in observational studies, without increased hemorrhagic complications. However, the quality of evidence remains weak. A summary of recommendations is provided to guide practice in common procedural scenarios. This Brief Practice Update provides evidence-based and expert consensus recommendations for the diagnosis and endovascular treatment of ICAS-LVO. Management should be individualized by incorporating the clinical presentation, imaging characteristics, and operator expertise. While adjunctive therapy may be beneficial in select cases, high-quality randomized trials are needed to define optimal strategies and establish standardized algorithms for this challenging stroke subtype.
SN - 2694-5746
ER -