Symptomatic Intracranial Atherosclerotic Disease

Symptomatic intracranial atherosclerotic disease (ICAD) has a high risk of recurrent stroke, and the risk increases with increasing stenosis. In patients with moderate-to-severe symptomatic stenosis, approximately 70% of recurrent strokes are ischemic stroke in the same territory, indicating that symptomatic ICAD is the main cause of recurrent strokes. Oral anticoagulation with warfarin is not recommended because of the higher risk of major bleeding and death compared to aspirin alone, and the benefit of direct oral anticoagulants remains unknown. Randomized controlled trials showed that angioplasty with or without stenting was inferior to intensive medical management alone, and accordingly it should be considered only for medically refractory severe symptomatic ICAD. The intensive medical management includes antiplatelet therapy, blood pressure control, lipid management with high intensity statins and diet control, smoking cessation, and physical activity. For recent symptomatic severe stenosis, short-term dual antiplatelet therapy with clopidogrel plus aspirin followed by antiplatelet monotherapy is recommended.