Intracranial Atherosclerotic Disease

Abstract

Intracranial atherosclerotic disease (ICAD) is the most common proximate mechanism of ischemic stroke worldwide. Approximately half of those affected are Asians. For diagnosis of ICAD, intra-arterial angiography is the gold standard to identify extent of stenosis. However, noninvasive techniques including transcranial ultrasound and MRA are now emerging as reliable modalities to exclude moderate to severe (50%–99%) stenosis. Little is known about measures for primary prevention of the disease. In terms of secondary prevention of stroke due to intracranial atherosclerotic stenosis, aspirin continues to be the preferred antiplatelet agent although clopidogrel along with aspirin has shown promise in the acute phase. Among Asians, cilostazol has shown a favorable effect on symptomatic stenosis and is of benefit in terms of fewer bleeds. Moreover, aggressive risk factor management alone and in combination with dual antiplatelets been shown to be most effective in this group of patients. Interventional trials on intracranial atherosclerotic stenosis have so far only been carried out among Caucasians and have not yielded consistent results. Since the Asian population is known to be preferentially effected, focused trials need to be performed to establish treatment modalities that are most effective in this population.

Primary Angioplasty without Stenting for Symptomatic, High-Grade Intracranial Stenosis with Poor Circulation

“…The 30-day rate of major stroke or death was 8.4% in the angioplasty group (8/95) versus 9.2% in the stent-placement group (9/98). 12 In our series of 35 patients treated during the past 6 years at a single institution, we found a 2.9% rate of major stroke or death at 1 month, which is comparable with rates in the existing literature on this topic. The 1-year stroke or death rate in our series was 6%, which was comparable with the 1-year stroke or death rate in the medical arm of the SAMMPRIS study.…”

Stroke in Asia: geographical variations and temporal trends

“…Large artery atherosclerosis is the predominant aetiology in most East Asian, South East Asian and South Asian countries. Atherosclerosis is, in most cases, affecting the intracranial vasculature and is suggested to be the most common cause of stroke in Asians 66. There are some data to suggest the high and rising burden of cardioembolic strokes, particularly from China and the Middle East 67…”

Primary balloon angioplasty for symptomatic, high-grade intracranial stenosis

“…[125] In the wake of these findings, there has been renewed interest in primary balloon angioplasty in this patient population. [9] This institutional series demonstrates the feasibility and relative safety of primary balloon angioplasty, and supports the incorporation of this technique into future trials that seek to identify high-risk populations that may benefit from angioplasty in conjunction with aggressive medical therapy for high-grade, symptomatic intracranial atherosclerosis.…”