Symptomatic Intracranial Atherosclerotic Disease

Blood Pressure Management

Post-hoc analysis of data from WASID demonstrated a statistically significant increase in recurrent stroke risk with increasing mean systolic and diastolic blood pressure (BP) [11]. This was particularly true in patients with mean SBP > 160 mm Hg. This is contrary to the common perception that BP should be maintained higher in patients with intracranial stenosis. In multivariable analysis, systolic BP greater than 140 mm Hg was associated with an increased risk of ischemic stroke, myocardial infarction, or vascular death. In the SAMMPRIS trial, the recommended BP goals for patients with symptomatic ICAD were less than 140/90 mm Hg in non-diabetic patients and less than 130/80 mm Hg in diabetic patients [7]. The timing and pace of blood pressure normalization for a recently symptomatic patient with ICAD is still unclear and needs further study.

Lifestyle Modification and Secondary Risk Factors

The SAMMPRIS protocol incorporated a lifestyle coach for all patients enrolled in the study. Lifestyle modification to achieve smoking cessation, regular physical activity, weight reduction for overweight patients, and glucose control in diabetes (goal hemoglobin A1c < 7.0%) were complementary to the pharmacotherapy (aspirin, clopidogrel, statin, and antihypertensive regimen) prescribed [7].

Patients should be encouraged to participate in aerobic exercise for at least 30 minutes at least 3 times weekly. Dietary modifications modeled after the Mediterranean diet should be encouraged. These should be coupled with additional efforts to address excessive weight as needed.

Successful smoking cessation proves one of the most challenging lifestyle modifications for this group of patients and may require the employment of an extended support system with both family and medical providers. Nicotine supplementation is a common first-line aid for cessation, which may be provided in the form of gum or transdermal patches. Additional pharmacotherapy to address central mechanisms of addiction may be necessary. Many patients benefit from the addition of an antidepressant therapy such as bupropion or an adjunctive medication such as varenicline (a nicotine receptor partial agonist that helps with breaking nicotine addiction). It is important to establish a quit date and detailed, multistep plan for cessation [12].

Exceptions and Other Considerations

These evidence-based recommendations are directed toward a specific group of patients with high-grade stenosis (70%–99%), a single symptomatic vessel, and relatively short segments of stenosis (< 14 mm) based on the inclusion and exclusion criteria for the SAMMPRIS trial [7]. Additionally, these patients were not enrolled during the immediate period following an acute ischemic event. There is less evidence on the management of patients who present with < 70% symptomatic ICAD but we can infer that therapy with DAT, statins, and risk factor modification are still of benefit for patients with 50%–69% stenosis or those requiring treatment during the acute evaluation [13]. Additionally, some of these SAMMPRIS exclusion criteria were included to select patients who could be considered intracranial stenting candidates (eg, short segment stenosis, single vessel disease, etc) and are not considered to impact on the benefits of the aggressive medical management regimen.