Purpose of review: : Large artery cerebrovascular disease accounts for approximately 20% of ischemic strokes. This review describes anatomic, epidemiologic, imaging, and therapeutic aspects of large vessel obstructive disease, with emphasis on revascularization methods.
Recent findings: : Considerable data have accumulated regarding the natural history, diagnosis, and optimal management of carotid disease, and the evidence regarding the optimal management of subclavian/brachiocephalic, vertebral, and intracranial obstructive disease continues to accrue. Advanced vascular imaging modalities have become integral to clinical decision making in the setting of complex cerebrovascular anatomy and physiology. The medical therapy and the surgical techniques have evolved remarkably over the past decades. Novel catheter-based endovascular therapies have rapidly emerged as an alternative or, in some cases, first-line treatment for large artery cerebrovascular disease.
Summary: : The evidence related to the diagnosis and treatment of large artery cerebrovascular disease has expanded remarkably. Sophisticated imaging protocols have minimized the need for invasive methods, and the efficacy of medical therapy (with newer antiplatelet agents and statins) has improved outcomes related to vascular disease. Endarterectomy and stenting have proven to be effective methods for carotid artery revascularization and stroke prevention. The best approach to patients with severe extracranial vertebral or intracranial stenosis warrants further investigation.