Management of Patients with Symptomatic Intracranial Atherosclerosis

Abstract

Intracranial atherosclerosis is a common cause of stroke, accounting for about 50% of ischaemic stroke in Asia and 8% in North America. Many prospective studies have confirmed that intracranial stenosis is an independent predictor for poor outcomes such as recurrent vascular event and death, despite the use of antiplatelet agents. The annual event rate is about 15% per year. The dismal outcome prompts the study of more aggressive treatment strategies, including warfarin and endovascular intervention. We have reviewed the published literature for the treatment of symptomatic intracranial stenosis. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial and Warfarin-Aspirin Recurrent Stroke Study (WARSS) studies failed to show that oral anticoagulation was better than aspirin in IAS. Initial encouraging results were found in the use of dual antiplatelet therapy in arresting the progression of stenosis. The results of the endovascular studies are mixed: there are more encouraging results with recent advances of technology in stent design, but a randomized controlled study is still lacking. Although there is still no established therapy for IAS, the results of ongoing randomized clinical trials to study dual antiplatelet agents and the use of endovascular intervention may soon provide clinicians with more evidence to better manage patients with this condition.

Efficacy and safety of different doses of intravenous tissue plasminogen activator in Chinese patients with ischemic stroke

“…In Chinese patients and other Asian groups, there is a greater incidence of small vessel disease and intracranial large vessel stenosis. 23 This has also led to the speculation that there may be differing dosing requirements in Asia.…”

Evolution of intracranial atherosclerotic disease under modern medical therapy

“…41 The medical management of ICAD has evolved dramatically in the past decade. 42 In this study, we extended the use of aspirin and clopidogrel to 4 weeks based on our initial experience of dual antiplatelets in reducing the frequency of ipsilateral distal microemboli. To test the true effect of dual antiplatelets, we excluded aspirin-failure patients to minimize the concern of aspirin resistance.…”

Standard of practice: endovascular treatment of intracranial atherosclerosis: Table 1

“…Angioplasty has been reported in many retrospective studies to have reasonable success rates with periprocedural complication rates reported of 4–40% 12 106. Initial series of angioplasty alone had higher complication rates but the technique of submaximal angioplasty, where the angioplasty balloon is undersized relative to the target vessel, appears to have lowered complications.…”