Abstract
Intracranial atherosclerotic disease (ICAD) is the most common proximate mechanism of ischemic stroke worldwide. Approximately half of those affected are Asians. For diagnosis of ICAD, intra-arterial angiography is the gold standard to identify extent of stenosis. However, noninvasive techniques including transcranial ultrasound and MRA are now emerging as reliable modalities to exclude moderate to severe (50%–99%) stenosis. Little is known about measures for primary prevention of the disease. In terms of secondary prevention of stroke due to intracranial atherosclerotic stenosis, aspirin continues to be the preferred antiplatelet agent although clopidogrel along with aspirin has shown promise in the acute phase. Among Asians, cilostazol has shown a favorable effect on symptomatic stenosis and is of benefit in terms of fewer bleeds. Moreover, aggressive risk factor management alone and in combination with dual antiplatelets been shown to be most effective in this group of patients. Interventional trials on intracranial atherosclerotic stenosis have so far only been carried out among Caucasians and have not yielded consistent results. Since the Asian population is known to be preferentially effected, focused trials need to be performed to establish treatment modalities that are most effective in this population.
Highlights
The Northern Manhattan stroke study [31] showed that the metabolic syndrome confers a greater risk of development of intracranial atherosclerotic strokes compared to extracranial atherothrombotic and non-atherothrombotic strokes. Another recent analysis [32] on WASID patients has shown that severity of stenosis depends most strongly on lipid disorder and has an association with diabetes and the metabolic syndrome
The stroke outcomes and neuroimaging of intracranial atherosclerosis (SONIA) trial [60] showed that both transcranial Doppler (TCD) and magnetic resonance angiography (MRA) identify 50% to 99% intracranial large vessel stenosis with a significant negative predictive value
Contrary to the common practice of permissive hypertension in highgrade stenosis, this study showed no increased risk with maintaining blood pressures in the normal range
Summary
Intracranial atherosclerotic stenosis of the major arteries (intracranial internal carotid artery, middle cerebral artery, vertebral artery, and basilar artery) is the most common proximate mechanism of ischemic stroke worldwide [1]. It causes 30% to 50% of strokes in Asians [2] and 8% to 10% of strokes in North American Caucasians [3]. Intracranial atherosclerotic disease, ICAD, defined as atherosclerosis of the large arteries at the base of the brain, preferentially affects Asians, Hispanics, Far East Asians, and Blacks as compared to carotid bifurcation disease [3,4,5,6].
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