Symptomatic Intracranial Atherosclerotic Disease

While the majority of patients will have no recurrent ischemic symptoms on aggressive medical therapy, some patients may continue to experience recurrent ischemic stroke or TIA secondary to ICAD despite optimal medical management. Patients who have hypoperfusion resulting in borderzone infarctions may be at higher risk for recurrent ischemic symptoms despite optimal medical therapy [20]. The risks of intracranial stenting, including stroke and death, must be weighed against the potential benefits. In the angioplasty plus stenting arm of the SAMMPRIS trial, the risk of stroke or death at 30 days was 14.7% [7]. In the angioplasty plus stenting arm of the VISSIT clinical trial evaluating symptomatic ICAD patients, the 30-day risk of stroke or death was 24% [21]. While intracranial angioplasty without stenting has been proposed as an alternative, there have been no randomized clinical trials to evaluate its efficacy beyond medical therapy alone in symptomatic ICAD patients. If endovascular treatment is considered, neuro-interventionists with high volume experience appear to have lower peri-procedural complications than those with low volume experience [22].

Another strategy that may be considered in symptomatic ICAD patients who have recurrent ischemic cerebral events due to symptomatic intracranial stenosis despite optimal medical therapy is indirect revascularization via encephaloduroarteriosynangiosis (EDAS). A single center retrospective study of 36 patients with ICAD and recent (< 30 days) TIAs or nondisabling strokes in the territory of the stenotic vessel (degree of stenosis not stated) and evidence of hypoperfusion and poor collateral flow on MR perfusion and/or conventional angiogram underwent EDAS [23]. Over a 2-year follow-up period, 5.6% of patients had ischemic strokes (1 stroke was periprocedural), compared with the estimated 17.2% risk of stroke in the SAMMPRIS cohort.

While endovascular and surgical techniques for revascularization of symptomatic ICAD are options for cases with medically refractory ischemic events due to hypoperfusion, further studies are needed to determine the safety of and optimal timing for these treatments.

Post-Discharge Follow-up Evaluation

At 1 month after discharge, the patient denied any new or recurrent signs or symptoms of stroke. Home blood pressure logs showed that BP was at target. Orthostatic BPs were assessed and no evidence of hypotension on standing was identified. Repeat laboratory evaluation was remarkable for hemoglobin A1c of 6.8% and LDL cholesterol of 64 mg/dL. The patient and his wife have been walking briskly 3 times per week for 45 minutes and continue to work on dietary modifications modeled after the Mediterranean diet. He is scheduled to follow up with his vascular neurologist 3 months after the stroke to discuss transition from DAT to aspirin monotherapy.

Conclusion

Intracranial atherosclerotic disease is a common cause of ischemic stroke, particularly amongst Asian, black, and Hispanic patients. Identification of ICAD can be performed with noninvasive arterial imaging including CT angiography or contrast-enhanced MR angiography as part of an ischemic stroke workup. Optimal medical management with early DAT with aspirin and clopidogrel along with aggressive risk factor and lifestyle modification has emerged as an effective first-line therapy. In patients with recurrent ischemic symptoms while optimally medically managed, endovascular therapy with angioplasty with or without stenting may be considered.

Corresponding author: Fadi Nahab, MD, 1635 Clifton Rd., Clinic B, Suite 2200, Atlanta, GA 30322, fnahab@emory.edu.

Financial disclosures: None.