Symptomatic intracranial arterial stenosis carries one of the highest rates of recurrent stroke (10%-20% per year) despite antithrombotic therapy. Stroke prevention strategies for intracranial atherosclerotic disease follow the guidelines for secondary stroke prevention that target atherogenic risk factors. These include following standard stroke prevention guidelines of weight loss for overweight patients, moderate physical exercise (at least 30 minutes most days), cessation of cigarette smoking, and a low-fat, low-cholesterol diet. Pharmacologic treatments include antiplatelet agents, statins, blood sugar control for diabetics, and antihypertensive medications. Goals may include low-density lipoprotein cholesterol less than 100 mg/dL (< 70 mg/dL in high-risk patients). The absolute blood pressure reduction target is uncertain, but average long-term reductions of 10/5 mm Hg are recom mended. Angio plasty with stent placement for the treatment of symptomatic severe intracranial stenosis (≥ 70%) is currently being evaluated in a phase 3 randomized controlled trial. It is unclear whether angioplasty with stent placement is superior to angioplasty alone for the treatment of intracranial stenosis, so both endovascular methods are currently acceptable. Complication and success rates for intra cranial angioplasty and stent placement are highly variable, so the widespread application of this procedure is generally not recommended outside of clinical trials and experienced centers.
Bibliographical noteFunding Information:
Dr. Qureshi has received support from the Minnesota Medical Foundation, National Institutes of Health, and American Heart Association.