http://circres.ahajournals.org/content/120/3/502?etoc=
Abstract
Our
goal in this review is to discuss the pathophysiology, diagnosis, and
treatment of stroke caused by atherosclerosis of the major intracranial
arteries. References for the review were identified by searching PubMed
for related studies published from 1955 to June 2016 using search terms
intracranial stenosis and intracranial atherosclerosis. Reference
sections of published randomized clinical trials and previously
published reviews were searched for additional references. Intracranial
atherosclerotic disease is a highly prevalent cause of stroke that is
associated with a high risk of recurrent stroke. It is more prevalent
among blacks, Hispanics, and Asians compared with whites. Diabetes
mellitus, hypertension, metabolic syndrome, smoking, hyperlipidemia, and
a sedentary lifestyle are the major modifiable risk factors associated
with intracranial atherosclerotic disease. Randomized clinical trials
comparing aggressive management (dual antiplatelet treatment for 90 days
followed by aspirin monotherapy and intensive management of vascular
risk factors) with intracranial stenting plus aggressive medical
management have shown medical management alone to be safer and more
effective for preventing stroke. As such, aggressive medical management
has become the standard of care for symptomatic patients with
intracranial atherosclerotic disease. Nevertheless, there are subgroups
of patients who are still at high risk of stroke despite being treated
with aggressive medical management. Future research should aim to
establish clinical, serological, and imaging biomarkers to identify
high-risk patients, and clinical trials evaluating novel therapies
should be focused on these patients.
Introduction
Atherosclerosis
in major intracranial arteries leads to changes ranging from minor wall
thickening to hemodynamically significant luminal stenosis and is one
of the most common causes of stroke worldwide.1
Intracranial atherosclerotic disease (ICAD) may occur concomitantly
with systemic atherosclerosis involving other arterial beds, such as
extracranial, coronary, or peripheral arteries, or may occur in
isolation.2,3
The middle cerebral arteries (MCAs) are the most common site, followed
by the basilar artery, the internal carotid arteries, and the
intracranial vertebral arteries.4,5 ICAD is highly prevalent in black, Asian (China, Japan, South Korea, and India), and Hispanic populations.1
As these populations are major drivers of global population growth, the
global stroke burden from ICAD is expected to rise over time.
Clinical
trials in the last decade have improved our understanding of the high
stroke recurrence rate in ICAD, risk factors, and neuroimaging
biomarkers associated with recurrence, as well as ushered in therapeutic
changes. In this study, we review the epidemiology, risk factors,
pathophysiology, diagnosis and management of ICAD.
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