Collateral Flow in Intracranial Atherosclerotic Disease

Transl Stroke Res. 2023 Feb;14(1):38-52. doi: 10.1007/s12975-022-01042-3. Epub 2022 Jun 8.


Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke and transient ischemic attack (TIA) worldwide. The culprit of ICAD is frequently a high-grade intracranial atherosclerotic stenosis (ICAS) pertaining to the infarct territory, and by then, the ICAS is described as symptomatic. A high-grade ICAS may progressively limit cerebral perfusion downstream, demanding collateral compensation. Collateral circulation refers to the pre-existing and dynamic emergence of vascular channels that maintain and compensate for a failing principal vascular route. Collaterals through the Circle of Willis and leptomeningeal circulation are of utmost importance in this regard. In this article, we first discussed the epidemiology, stroke mechanisms, contemporary therapeutics, and prognosis of symptomatic ICAD. Then, we reviewed the collateral routes in ICAS, factors associated with recruitment and development of the collaterals and diagnostic imaging modalities in assessing the origin and function of collateral circulation. We discussed the associations between collateral circulation and clinical outcomes after acute reperfusion treatment in ICAD-related ischemic strokes with or without large vessel occlusion (LVO). We also conducted a systematic review and meta-analysis on the associations of collateral circulation with the risk of recurrent stroke and the functional outcome in symptomatic ICAS patients on medical treatment as secondary stroke prevention. Finally, we summarized current evidence in these aspects and proposed the future directions.

Keywords: Collateral circulation; Intracranial atherosclerotic disease; Ischemic stroke.

Publication types

  • Systematic Review
  • Meta-Analysis
  • Review
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cerebral Infarction / complications
  • Cerebrovascular Circulation
  • Collateral Circulation
  • Humans
  • Intracranial Arteriosclerosis* / complications
  • Intracranial Arteriosclerosis* / diagnostic imaging
  • Intracranial Arteriosclerosis* / epidemiology
  • Ischemic Attack, Transient* / complications
  • Prognosis
  • Stroke* / diagnostic imaging
  • Stroke* / epidemiology
  • Stroke* / etiology