New Guidance Issued for Secondary Prevention in Intracranial Atherosclerosis

Tanya Turan, MD, MSCR

The American Academy of Neurology (AAN) has released new guidance for secondary prevention in patients with intracranial atherosclerosis in a practice advisory published in Neurology.

With endorsements from the American Heart Association/American Stroke Association, Neurocritical Care Society, and Society of Vascular and Interventional Neurology, the new guidance was published on March 21, 2022 and advocates for an approach focused on optimizing use of medications and exercise than placing a stent in the blood vessel for preventing recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS).

“People who have had this type of stroke should first be started on medications to prevent blood clots, reduce blood pressure and cholesterol and safely start increasing their physical activity as recommended by their doctors to decrease the risk of another stroke,” said practice advisory author Tanya Turan, MD, MSCR, of the Medical University of South Carolina in Charleston and a Fellow of the American Academy of Neurology, in a statement from the AAN. “Having a stent placed in the blood vessel of the brain should not be the first option of care for most people.”

Developed using the process outlined in the AAN’s 2011 Clinical Practice Guideline Process Manual, the 13-page document is based on a systematic review of studies published through November 2020 performed by Turan and a team of 18 colleagues representing institutions across the US. The review process consisted of 2 separate literature evaluations. The first search queried the MEDLINE, Cochrane, and Science Citation index databases from inception through 2016 and resulted in 45 articles being included for the analysis and evidence rating. A second literature search following the same process was performed in November 2020 and this results in 11 new articles being selected to inform the guideline writing process.

The practice advisory included multiple major recommendations, which can be found listed below:

• Clinicians 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 LDL-C level of less than70 mg/dL, a long-term blood pressure target of less than 140/90 mmHg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS.
• Clinicians should not be recommending 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 be routinely recommending angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials nor should clinicians recommend direct bypass for stroke prevention in patients with sICAS. If one of these procedures is being contemplated, clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments.

“Reviewing all of the evidence that has accumulated over the last two decades, we found that the research shows that medical management is more beneficial for people as an initial treatment,” Turan added.

This article, titled “Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory,” was published in Neurology.