Surgery and neurointervention for intracranial atherosclerotic steno-occlusive disease

Neurosurgeons and neurointerventionists interested in cerebral revascularisation to prevent stroke from intracranial atherosclerotic steno-occlusive disease were disappointed in 2011 with the closure of two important negative studies: the Carotid Occlusion Surgery Study (COSS) and Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study. Debates are centred on what causes these failures. While extracranial-intracranial (EC-IC) bypass and neurointervention (angioplasty and/ or stenting) cannot be considered a routine intervention for patients presenting with initial ischaemic event in the setting of atherosclerotic steno-occlusive disease, selected patients with severe haemodynamic impairment and/or recurrent symptoms despite maximal medical therapy may still benefit from surgery and neurointervention at high-volume centres, which can offer the procedure with low perioperative morbidity.