What are the AHA/ASA guidelines on secondary stroke prevention in patients with intracranial atherosclerosis?

Updated: Jan 10, 2016
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Answer

Based on outcome findings of a meta-analysis of comparative trials, the AHA/ASA guidelines have changed from a class I to a class IIa the recommendation of carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients in whom the diameter of the lumen of the internal carotid artery is reduced by >70%, on noninvasive imaging studies, or by >50% on catheter-based imaging or noninvasive imaging with corroboration.

The guidelines also provide a new class IIa recommendation that for older patients (>70 years), outcomes may be better with CEA than withCAS, particularly in patients with arterial anatomy unfavorable for endovascular intervention. In  younger patients, CAS and CEA have comparable outcomes. [7]

Recommendations for patients with stroke or TIA attributable to intracranial atherosclerosis include the following:

  • For patients with severe stenosis (≥70%) of a major intracranial artery: Within 30 days of the stroke or TIA, the addition of clopidogrel 75 mg/d to aspirin for 90 days (class IIb); stenting with the Wingspan stent system is not recommended as an initial treatment (class III) and angioplasty alone or placement of stents other than Wingspan is considered investigational (class IIb)
  • For patients with stenosis (≥50%) of a major intracranial artery: Maintenance of systolic BP below 140 mm Hg and high-intensity statin therapy (class I); however, there is insufficient evidence that clopidogrel alone, the combination of aspirin and dipyridamole, or cilostazol alone is useful (class IIb)
  • For patients with stenosis (50% to <70%) of a major intracranial artery: Angioplasty or stenting is not recommended (class III)

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