From the Guidelines
The management of severe cerebral artery stenosis should prioritize a multifaceted approach, including aggressive medical therapy and consideration of revascularization within two weeks of symptom onset, as supported by the most recent guidelines 1. The initial management includes aggressive medical therapy with antiplatelet agents such as aspirin (75-325 mg daily) combined with clopidogrel (75 mg daily) for 21-90 days, followed by aspirin monotherapy long-term. High-intensity statin therapy with atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) is essential to stabilize plaques and reduce stroke risk, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. Some key points to consider in the management of severe cerebral artery stenosis include:
- Blood pressure should be controlled to targets below 140/90 mmHg using antihypertensives like ACE inhibitors or ARBs.
- For patients with symptomatic high-grade stenosis (70-99%), revascularization should be considered within two weeks of symptom onset, with carotid endarterectomy preferred for most patients with suitable anatomy and low surgical risk, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
- Carotid artery stenting may be appropriate for those with high surgical risk or specific anatomical considerations.
- For intracranial stenosis, medical management is typically preferred over stenting, as indicated by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. Regular follow-up with carotid ultrasound every 6-12 months is recommended to monitor disease progression. Lifestyle modifications including smoking cessation, diabetes management, regular exercise, and Mediterranean diet are crucial components of long-term management, as they address both immediate stroke risk reduction and long-term prevention of cerebrovascular events. It is also important to note that the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown for patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high-intensity statin therapy, as stated in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
From the Research
Management of Severe Cerebral Artery Stenosis
The management of patients with severe cerebral artery stenosis involves a combination of medical, surgical, and endovascular treatments. The goal of treatment is to prevent stroke and other vascular events.
Medical Treatment
- Aspirin is commonly recommended for patients with symptomatic and asymptomatic carotid artery stenosis, as it has been shown to reduce the risk of vascular events 2.
- Statins have also been demonstrated to prevent stroke and slow or halt atherosclerosis progression in patients with intracranial arterial stenosis 3.
- Antiplatelet therapy, such as aspirin or clopidogrel, is also recommended for patients with carotid stenosis, as it has been shown to reduce the risk of recurrent vascular events 4, 5.
Surgical Treatment
- Carotid endarterectomy (CEA) is recommended for patients with ≥70-99% symptomatic stenosis, and may be considered for patients with 50-69% symptomatic stenosis 6.
- CEA is also recommended for patients with ≥60-99% asymptomatic carotid stenosis who are considered to be at increased risk of stroke on best medical treatment alone 6.
Endovascular Treatment
- Carotid artery stenting (CAS) may be considered in patients <70 years old with symptomatic ≥50-99% carotid stenosis, based on low quality evidence 6.
Timing of Treatment
- CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischemic event in patients with ≥50-99% symptomatic stenosis, based on high quality evidence 6.