Abstract
Background and ObjectivesTo review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS).MethodsThe development of this practice advisory followed the process outlined in the American Academy of Neurology Clinical Practice Guideline Process Manual, 2011 Edition, as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences.Major RecommendationsClinicians should recommend aspirin 325 mg/d for long-term prevention of stroke and death and should recommend adding clopidogrel 75 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with severe (70%-99%) sICAS who have low risk of hemorrhagic transformation. Clinicians should recommend high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol level <70 mg/dL, a long-term blood pressure target of <140/90 mm Hg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS. Clinicians should not recommend percutaneous transluminal angioplasty and stenting for stroke prevention in patients with moderate (50%-69%) sICAS or as the initial treatment for stroke prevention in patients with severe sICAS. Clinicians should not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.
| Original language | English |
|---|---|
| Pages (from-to) | 486-498 |
| Number of pages | 13 |
| Journal | Neurology |
| Volume | 98 |
| Issue number | 12 |
| DOIs | |
| State | Published - Mar 22 2022 |
Bibliographical note
Publisher Copyright:© American Academy of Neurology.
Funding
This practice advisory was developed with financial support from the AAN. Authors who have served as AAN subcommittee members (S.R.M., J.J.F., G.S.G.) or who are or were AAN staff (M.D.O., H.S.) were reimbursed by the AAN for expenses related to travel to subcommittee meetings where drafts of manuscripts were reviewed. T. Turan has received research support from the NIH for the SAMMPRIS, CREST 2, SE-CoAST StrokeNet RCC, and CHAMPION studies, as well as for serving on the event adjudication committee for the VERiTAS clinical trial; has received personal compensation in the range of $10,000–$49,999 for serving as a blinded clinical events adjudicator for Pfizer and Boehringer Ingelheim; has received personal compensation in the range of $500–$4,999 for serving as a blinded clinical events adjudicator for trials unrelated to intracranial stenosis for W.L. Gore & Associates; and has received publishing royalties from a publication relating to health care. O. Zaidat has received personal compensation for consulting work unrelated to intracranial atherosclerosis and research support from Stryker, Cerenovous, Penumbra, and Medtronic; is the co-chair of the endovascular committee for the NIH StokeNet, the co-editor in chief for the Endovascular and Interventional Neurology section of Frontiers in Neurology, and a past president of the Society of Vascular and Interventional Neurology; and is a founder of Galaxy Therapeutics, Inc. G. Gronseth has received personal compensation in the range of $0–$499 for serving as an editor, associate editor, or editorial advisory board member for Brain & Life and has received personal compensation in the range of $10,000–$49,999 for serving as an associate editor of Neurology®; and has received personal compensation in the range of $0–$499 for serving as an evidence-based medicine consultant for the AAN Guidelines Subcommittee. M. Chimowitz has received product support from Stryker Neurovascular, AstraZeneca, Bayer AG, and Bristol Myers Squibb for the NIH-funded SAMMPRIS and WASID trials; has received personal fees from Gore, Medtronic, Merck & Co., Parexel, and NoNO Inc. for participating as a member of a data and safety monitoring board or stroke adjudicator in clinical trials unrelated to intracranial stenosis; has received funding from the NIH for the SAMMPRIS and WASID trials and the NIH Wingspan registry; has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for NoNO Inc.; and his institution has received research support from the NIH. A. Culebras has served on UpToDate and MedLink Neurology editorial boards. A. Furlan has nothing to disclose. L. Goldstein has served on scientific advisory boards for Daiichi Sankyo and Merz; has received funding for travel from Pfizer, Daiichi Sankyo, and the National Lipid Association to attend scientific meetings to discuss SPARCL studies; has received publishing royalties from UpToDate, Henry Stewart Publications, and Wiley; has received research support from St. Jude Medical, Inc., for the RESPECT trial, from Nexstim for the NICHE trial, and from the NIH; has received intellectual property interests from a publication relating to health care; and his institution has received research support from the NIH; has received compensation for consulting work from Nestlé, Artemida, Roche, Abbott, and Shire; has received compensation for participating in a data safety monitoring board from Artemida and Roche; and has received an honorarium from the American Heart Association (AHA). N. Gonzalez has received research support from the NIH and the AHA. J. Latorre has nothing to disclose. S. Messé has received funding for travel from the AAN; has received publishing royalties from articles written for UpToDate, including articles about antiplatelets for secondary stroke prevention, carotid disease and surgery, and patent foramen ovale (PFO) and stroke; has received compensation from the Yale Cardiovascular Research Group for serving on clinical event committees for trials of embolic protection during valve replacement and a registry of left atrial appendage occluder placement; has received research support from W.L. Gore & Associates for a PFO closure study and a study of proximal aortic repair, from Novartis for a study of medication to reduce inflammation after intracerebral hemorrhage, from Biogen for a study of a medication to reduce edema from malignant infarction, and from the NIH for a study examining an embolic protection in aortic valve replacement, a cohort study examining renal insufficiency, and a study of sleep apnea treatment after acute stroke; and is a cofounder of and has equity in Neuralert Technologies, a company developing monitors to detect in-hospital stroke. T. Nguyen serves as editor of Frontiers in Neurology; has received compensation as a consultant for Avania; and has received research support from Medtronic and the Society of Vascular and Interventional Neurology. R. Sangha has nothing to disclose. M. Schneck has served on the editorial boards of the Journal of Stroke and Cerebrovascular Disease and Frontiers in Neurology and owns mutual funds that include health retail business stock; has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for HLT; has received personal compensation in the range of $10,000–$49,999 for serving as an expert witness for miscellaneous legal firms; an immediate family member has received personal compensation for serving as an employee of HistoGeneX; and his institution has received research support from the NIH. A. Singhal has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Omniox, Deck Therapeutics, Proneurotech, MedLink, and UpToDate; and has served as an expert in legal cases, holds stock and/or stock options in Biogen and Zafgen, and has received research support from the NIH-NINDS for serving as deputy principal investigator (PI) of the New England Regional Coordinating Center for the NIH StrokeNet, site PI of the ARCADIA trial, and data safety monitoring board chair of the FEASt trial. L. Wechsler has served on a SanBio Company Limited scientific advisory board and holds stock in Silk Road Medical and Forest Devices; and his institution has received research support from NINDS. A. Rabinstein has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for Boston Scientific and Boehringer-Ingelheim, has received personal compensation in the range of $0–$499 for serving on a scientific advisory or data safety monitoring board for Minnetronix Medical, has received personal compensation in the range of $500–$4,999 for serving as an editor, associate editor, or editorial advisory board member for Neurocritical Care and UpToDate; has received publishing royalties from a publication relating to health care; and his institution has received research support from Oculogica. M. Dolan O'Brien is an employee of the American Academy of Neurology. H. Silsbee is an employee of the American Academy of Neurology. J. Fletcher has nothing to disclose. Go to Neurology.org/N for full disclosures.
| Funders | Funder number |
|---|---|
| Artemida | |
| NoNO Inc. | |
| Stryker Neurovascular | |
| Yale Cardiovascular Research Group | |
| National Institutes of Health (NIH) | |
| American the American Heart Association | |
| Abbott Laboratories | |
| Bristol-Myers Squibb | |
| Pfizer | |
| AstraZeneca | |
| Bayer AG | |
| Merck | |
| Novartis | |
| Roche Diagnostics | |
| Medtronic | |
| American Academy of Neurology | |
| Biogen IDEC | |
| St. Jude Medical Center | |
| National Lipid Association | |
| Daiichi Sankyo Company, Limited | |
| Shire |
ASJC Scopus subject areas
- Clinical Neurology