Symptomatic intracranial atherosclerotic arterial stenosis (sICAS) is one of the most common causes of stroke worldwide and is associated with a high risk of recurrent stroke. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated. Clinicians should not recommend direct bypass for stroke prevention in patients with 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 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 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. From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY Department of Neurology (A.J.F.), Cleveland Medical Center, OH Department of Neurology (L.B.G.), University of Kentucky, Lexington Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA Department of Neurology (R.S.S.), University of Alabama, Birmingham Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston Department of Neurology (A.A.R.), Mayo Clinic, Rochester American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids.Ĭlinicians 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.
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