What is the treatment for symptomatic intracranial stenosis?

Treatment for Symptomatic Intracranial Stenosis

Medical management is the first-line treatment for symptomatic intracranial stenosis, consisting of dual antiplatelet therapy for up to 90 days followed by single antiplatelet therapy, along with aggressive risk factor modification. 1, 2, 3

Medical Management Protocol

Antiplatelet Therapy

• Initial therapy: Dual antiplatelet therapy with aspirin 325 mg daily plus clopidogrel 75 mg daily for up to 90 days 1, 2, 3
• Long-term therapy: Single antiplatelet therapy with aspirin 50-325 mg daily after the initial 90-day period 2, 3
• For patients with recent minor stroke or high-risk TIA (within 24 hours) with >30% stenosis, consider adding ticagrelor 90 mg twice daily to aspirin for up to 30 days 2

Risk Factor Management

1. Blood pressure control:

   • Target BP <140/90 mmHg 2, 3
   • Preferred agents: thiazide diuretics, ACE inhibitors, or ARBs 2, 3

2. Lipid management:

   • High-intensity statin therapy regardless of baseline LDL levels 2
   • Target LDL <70 mg/dL 2, 3
   • Consider adding ezetimibe or PCSK9 inhibitors for patients who fail to reach targets or have statin intolerance 3

3. Diabetes management:

   • Target HbA1c ≤7% through diet, insulin, and hypoglycemic medications 3

4. Lifestyle modifications:

   • Smoking cessation 2, 4
   • Weight reduction (target BMI <25 kg/m²) 2, 4
   • Physical activity: minimum 10 minutes of moderate-intensity aerobic activity 4 times weekly for capable patients 2, 3

Interventional Procedures

Intracranial stenting is not recommended as initial treatment for symptomatic intracranial stenosis, even in patients who were taking antithrombotic agents at the time of stroke/TIA 1, 2. The evidence shows:

• Excess morbidity and mortality with interventional approaches compared to medical management 2
• Periprocedural complication rates of 4.5-14.7% for Wingspan stent 2
• Restenosis concerns (20-32% of cases) 2

Limited Role for Intervention

Angioplasty or stenting may only be considered in highly selected cases with:

• Severe stenosis (70-99%) 1, 2
• Actively progressing symptoms or recurrent TIA/stroke despite optimal medical therapy 1, 2
• Performed only at high-volume centers with significant neurovascular expertise 1, 2

Follow-up and Monitoring

• Regular assessment of medication adherence and side effects 2
• Serial noninvasive imaging to assess progression of atherosclerotic disease 2
• Monitoring of risk factor control (blood pressure, lipids, etc.) 2

Important Caveats

• Early aggressive medical management is crucial, as the highest risk of recurrent stroke is within the first 30 days after the initial event 1, 5
• Extracranial-intracranial bypass surgery is not recommended for patients with 50-99% stenosis or occlusion of major intracranial arteries 2
• Despite optimal medical therapy, real-world recurrent stroke rates may be higher than those observed in clinical trials 5
• Adherence to all components of aggressive medical management is essential for optimal outcomes 4