Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory

Abstract

Background and ObjectivesTo review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS).MethodsThe development of this practice advisory followed the process outlined in the American Academy of Neurology Clinical Practice Guideline Process Manual, 2011 Edition, as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences.Major RecommendationsClinicians should recommend aspirin 325 mg/d for long-term prevention of stroke and death and should recommend adding clopidogrel 75 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with severe (70%–99%) sICAS who have low risk of hemorrhagic transformation. Clinicians should recommend high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol level <70 mg/dL, a long-term blood pressure target of <140/90 mm Hg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS. Clinicians should not recommend percutaneous transluminal angioplasty and stenting for stroke prevention in patients with moderate (50%–69%) sICAS or as the initial treatment for stroke prevention in patients with severe sICAS. Clinicians should not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.

Stroke incidence and cognitive outcomes of intracranial atherosclerotic stenosis: study protocol for a multicenter, prospective, observational cohort study

“…), ischemic stroke recurrence, cognitive impairment, other acute vascular events, and vascular death events. Individual treatments applied in the remaining centers will comply with the clinical guidelines ( 31 ).…”

Recent advances in the management of transient ischemic attacks

“…Data for vertebral artery stenting are not as voluminous as those for carotid stenting. However, the most recent guidelines emphasize the primacy of medical therapy and the need for ongoing clinical trials 148 .…”

“…The current recommendations are to manage these patients with “maximal medical therapy” 95 , 146 . Nevertheless, it is reasonable to consult expert operators, particularly if these patients remain symptomatic with multiple recurrent TIAs despite conservative management 148 .…”

Reply: Antiplatelet Use in Ischemic Stroke

“…A recent ICAD review does not recommend percutaneous transluminal angioplasty and stenting (PTAS) following the findings of the SAMMPRIS and VISSIT trials (Level B evidence). 3,6,7 The high rate of peri-procedural stroke in SAMMPRIS is deemed not to have been affected by operator experience, as the post-hoc analysis did not show a higher complication rate among less experienced surgeons. 8 Despite the higher rate of stroke, death and hemorrhage in the PTAS group of SAMMPRIS, which used the Wingspan stent system, this device controversially remains food and drug administration (FDA)-approved, although now with stricter usage criteria.…”

“…2 Recommendations for up to 90 days of DAPT in severe cases of ICAD (70%-99% stenosis) with low risk of haemorrhagic transformation have also been echoed by a recent systematic review (Level B evidence). 3…”