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Abstract
Purpose of the Review This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery.
Recent Findings Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT.
Summary ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.
Glossary
- CASSISS=
- China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis;
- CHANCE=
- Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events;
- CI=
- confidence interval;
- CLAIR=
- Clopidogrel Plus Aspirin Versus Aspirin Alone for Reducing Embolization in Patients With Acute Symptomatic Cerebral or Carotid Stenosis;
- CREST=
- Carotid Revascularization Endarterectomy Versus Stenting Trial;
- CTA=
- CT angiography;
- DAPT=
- dual antiplatelet therapy;
- DSA=
- digital subtraction angiography;
- EC-IC=
- extracranial-intracranial;
- EDAS=
- encephaloduroarteriosynangiosis;
- ESPRIT=
- European/Australian Stroke Prevention in Reversible Ischemia;
- FISS-tris=
- Fraxiparin in Stroke Study for the Treatment of Ischemic Stroke;
- HR=
- hazard ratio;
- HRvwMRI=
- high-resolution vessel wall MRI;
- ICAD=
- intracranial atherosclerotic disease;
- LDL-C=
- low-density lipoprotein cholesterol;
- MCA=
- middle cerebral artery;
- MMT=
- maximal medical therapy;
- MRA=
- magnetic resonance angiography;
- MT=
- mechanical thrombectomy;
- POINT=
- Platelet-Oriented Inhibition in New TIA and Minor Stroke;
- PTAS=
- percutaneous transluminal angioplasty and stenting;
- SAMMPRIS=
- Stenting Versus Aggressive Medical Management Therapy for Intracranial Arterial Stenosis;
- SOCRATES=
- Acute Stroke or Transient Ischemic Attack With Aspirin or Ticagrelor and Patient Outcomes;
- SPARCL=
- Stroke Prevention by Aggressive Reduction in Cholesterol Levels;
- TCD=
- transcranial Doppler;
- THALES=
- Acute Stroke or Transient Ischemic Attack Treated With Ticagrelor and Aspirin for Prevention of Stroke and Death;
- TOSS=
- Trial for Cilostazol in Symptomatic Intracranial Arterial Stenosis;
- VISSIT=
- Vitesse Intracranial Stent Study for Ischemic Stroke Therapy;
- VMR=
- vasomotor reactivity;
- WASID=
- Warfarin-Aspirin Symptomatic Intracranial Disease;
- WEAVE=
- Wingspan Stent System Post Market Surveillance;
- WOVEN=
- Wingspan One-Year Vascular Events and Neurologic Outcomes
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 28, 2020.
- Accepted in final form March 5, 2021.
- © 2021 American Academy of Neurology
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- Abstract
- Glossary
- Epidemiology
- Pathology
- Mechanism of Stroke
- Clinical Course
- Diagnostic Evaluation
- Medical Treatment
- Antiplatelets
- Anticoagulation
- Risk Factor Management
- Intracranial Angioplasty and Stenting
- Future Direction for PTAS
- Patient Selection
- Timing of Stenting
- Operator Experience
- Stent/Balloon Technology
- Direct and Indirect Surgical Revascularization
- Mechanical Thrombectomy in ICAD
- Conclusion
- Study Funding
- Disclosure
- Appendix Authors
- Footnotes
- References
- Figures & Data
- Info & Disclosures
