WSC 2025 | How should hemodynamic considerations influence the management of ICAD?

At the Toronto Western Hospital, we developed a revascularization clinic where vascular neurosurgeons, vascular neurologists, and diagnostic and interventional neuroradiologists work together to look at every patient in terms of their symptomatology, their risk factors, and if they seem to have hemodynamic symptoms, and we need to specifically ask for those as physicians, along with signs of hemodynamic compromise on imaging. First of all, we always offer aggressive medical management to improve and optimize flow. However, if those seem to fail, and when we select patients who are at the highest risk for stroke, the threshold to go ahead with an intervention goes down because we know now that endovascular measures such as stenting or submaximal angioplasty in perforator-rich areas in patients who have a stenosis and not an occlusion. There is a signal in the latest trials that that can improve outcomes, especially over the long term, as well as in patients with occlusions to offer bypass surgery. Due to improved interventional techniques, the complication risk is decreasing, especially because we start to know better about the timing and selection of patients. And still, it is an investment in the future of patients because you take an upfront risk for an intervention in order to prevent long-term stroke risk. And now we learn more and more how these interventions actually improve or reduce the stroke risk over the long-term in patients. So there is hope for them that we are not just waiting until they get another stroke, but we can offer more imaging and treatment modalities for them.

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