Practice Guideline

. 2022 Mar 22;98(12):486-498.

doi: 10.1212/WNL.0000000000200030.

Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee

Tanya N Turan¹, Osama O Zaidat¹, Gary S Gronseth¹, Marc I Chimowitz¹, Antonio Culebras¹, Anthony J Furlan¹, Larry B Goldstein¹, Nestor R Gonzalez¹, Julius G Latorre¹, Steven R Messé¹, Thanh N Nguyen¹, Rajbeer S Sangha¹, Michael J Schneck¹, Aneesh B Singhal¹, Lawrence R Wechsler¹, Alejandro A Rabinstein¹, Mary Dolan O'Brien¹, Heather Silsbee², Jeffrey J Fletcher¹

Affiliations

¹ 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.
² 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. guidelines@aan.com.

PMID: 35314513
PMCID: PMC8967328
DOI: 10.1212/WNL.0000000000200030

Practice Guideline

Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee

Tanya N Turan et al. Neurology. 2022.

. 2022 Mar 22;98(12):486-498.

doi: 10.1212/WNL.0000000000200030.

Authors

Affiliations

¹ 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.
² 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. guidelines@aan.com.

PMID: 35314513
PMCID: PMC8967328
DOI: 10.1212/WNL.0000000000200030

Abstract

Background and objectives: To review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS).

Methods: The development of this practice advisory followed the process outlined in the American Academy of Neurology Clinical Practice Guideline Process Manual, 2011 Edition, as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences.

Major recommendations: 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 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. 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 not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.

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Figures

**Figure 1. Summary Estimate of the Effects of PTAS + AMM Compared to AMM Alone on 30-Day Risk of Recurrent Stroke or Death**
AMM = aggressive medical management; PTAS = percutaneous transluminal angioplasty and stenting; SAMMPRIS = Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; VISSIT = Vitesse Intracranial Stent Study for Ischemic Therapy

**Figure 2. Summary Estimate of the Effects of PTAS + AMM Compared to AMM Alone on Recurrent Stroke or Death Beyond 30 Days**
AMM = aggressive medical management; PTAS = percutaneous transluminal angioplasty and stenting; SAMMPRIS = Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; VISSIT = Vitesse Intracranial Stent Study for Ischemic Therapy

See this image and copyright information in PMC

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Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee

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Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee

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