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Life sciences · Review
Stroke Vascular and Interventional Neurology · November 1, 2026
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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.