Intracranial atherosclerotic disease


Opinion statement

Symptomatic intracranial arterial stenosis carries one of the highest rates of recurrent stroke (10%–20% per year) despite antithrombotic therapy. Stroke prevention strategies for intracranial atherosclerotic disease follow the guidelines for secondary stroke prevention that target atherogenic risk factors. These include following standard stroke prevention guidelines of weight loss for overweight patients, moderate physical exercise (at least 30 minutes most days), cessation of cigarette smoking, and a low-fat, low-cholesterol diet. Pharmacologic treatments include antiplatelet agents, statins, blood sugar control for diabetics, and antihypertensive medications. Goals may include low-density lipoprotein cholesterol less than 100 mg/dL (< 70 mg/dL in high-risk patients). The absolute blood pressure reduction target is uncertain, but average long-term reductions of 10/5 mm Hg are recom mended. Angio plasty with stent placement for the treatment of symptomatic severe intracranial stenosis (≥ 70%) is currently being evaluated in a phase 3 randomized controlled trial. It is unclear whether angioplasty with stent placement is superior to angioplasty alone for the treatment of intracranial stenosis, so both endovascular methods are currently acceptable. Complication and success rates for intra cranial angioplasty and stent placement are highly variable, so the widespread application of this procedure is generally not recommended outside of clinical trials and experienced centers.

References and Recommended Reading

  1. 1.
    Sacco RL, Kargman DE, Gu Q, Zamanillo MC: Raceethnicity and determinants of intracranial atherosclerotic cerebral infarction: The Northern Manhattan Stroke Study. Stroke 1995, 26:14–20.PubMedGoogle Scholar
  2. 2.
    Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Trial Investigators: Design, progress and challenges of a double-blind trial of warfarin versus aspirin for symptomatic intracranial arterial stenosis. Neuroepidemiology 2003, 22:106–117.CrossRefGoogle Scholar
  3. 3.
    Qureshi AI, Ziai WC, Yahia AM, et al.: Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: a multicenter study. Neurosurgery 2003, 52:1033–1039.CrossRefPubMedGoogle Scholar
  4. 4.
    Chimowitz MI, Lynn MJ, Howlett-Smith H, et al.: Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005, 352:1305–1316.CrossRefPubMedGoogle Scholar
  5. 5.
    Kasner SE, Chimowitz MI, Lynn MJ, et al.: Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation 2006, 113:555–563.CrossRefPubMedGoogle Scholar
  6. 6.
    Jarvis AL, Chimowitz M, Lynn MJ, et al.: Outcome of patients with 50–99% intracranial stenosis and TIA or stroke on antithrombotic therapy treated medically vs. stenting. Presented at the 60th Annual Meeting of the American Academy of Neurology. Chicago; April 17, 2008.Google Scholar
  7. 7.
    Derdeyn CP, Chimowitz MI: Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am 2007, 17:355–363.CrossRefPubMedGoogle Scholar
  8. 8.
    Moossy J: Pathology of cerebral atherosclerosis. Influence of age, race, and gender. Stroke 1993, 24:I22–23, I31–22.PubMedGoogle Scholar
  9. 9.
    Passero S, Rossi G, Nardini M, et al.: Italian multicenter study of reversible cerebral ischemic attacks. Part 5. Risk factors and cerebral atherosclerosis. Atherosclerosis 1987, 63:211–224.CrossRefPubMedGoogle Scholar
  10. 10.
    Velican C, Anghelescu M, Velican D: Preliminary study on the natural history of cerebral atherosclerosis. Med Interne 1981, 19:137–145.Google Scholar
  11. 11.
    Bae HJ, Lee J, Park JM, et al.: Risk factors of intracranial cerebral atherosclerosis among asymptomatics. Cerebrovasc Dis 2007, 24:355–360.CrossRefPubMedGoogle Scholar
  12. 12.
    Huang HW, Guo MH, Lin RJ, et al.: Prevalence and risk factors of middle cerebral artery stenosis in asymptomatic residents in Rongqi County, Guangdong. Cerebrovasc Dis 2007, 24:111–115.CrossRefPubMedGoogle Scholar
  13. 13.
    Uehara T, Tabuchi M, Mori E: Risk factors for occlusive lesions of intracranial arteries in stroke-free Japanese. Eur J Neurol 2005, 12:218–222.CrossRefPubMedGoogle Scholar
  14. 14.
    Lloyd-Jones D, Adams R, Carnethon M, et al.: Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009, 119:e21–e181.CrossRefPubMedGoogle Scholar
  15. 15.
    Resch JA, Okabe N, Loewenson R, et al.: A comparative study of cerebral atherosclerosis in a Japanese and Minnesota population. J Atheroscler Res 1967, 7:687–693.CrossRefPubMedGoogle Scholar
  16. 16.
    White H, Boden-Albala B, Wang C, et al.: Ischemic stroke subtype incidence among whites, blacks, and Hispanics: The Northern Manhattan Study. Circulation 2005, 111:1327–1331.CrossRefPubMedGoogle Scholar
  17. 17.
    Sertic J, Hebrang D, Janus D, et al.: Association between deletion polymorphism of the angiotensin-converting enzyme gene and cerebral atherosclerosis. Eur J Clin Chem Clin Biochem 1996, 34:301–304.PubMedGoogle Scholar
  18. 18.
    Arenillas JF, Alvarez-Sabin J, Montaner J, et al.: Angiogenesis in symptomatic intracranial atherosclerosis: predominance of the inhibitor endostatin is related to a greater extent and risk of recurrence. Stroke 2005, 36:92–97.CrossRefPubMedGoogle Scholar
  19. 19.
    Kolsch H, Larionov S, Dedeck O, et al.: Association of the glutathione S-transferase omega-1 Ala140Asp polymorphism with cerebrovascular atherosclerosis and plaque-associated interleukin-1 alpha expression. Stroke 2007, 38:2847–2850.CrossRefPubMedGoogle Scholar
  20. 20.
    Yoo JH, Chung CS, Kang SS: Relation of plasma homocyst(e)ine to cerebral infarction and cerebral atherosclerosis. Stroke 1998, 29:2478–2483.PubMedGoogle Scholar
  21. 21.
    Leung SY, Ng TH, Yuen ST, et al.: Pattern of cerebral atherosclerosis in Hong Kong Chinese. Severity in intracranial and extracranial vessels. Stroke 1993, 24:779–786.PubMedGoogle Scholar
  22. 22.
    Chaturvedi S, Turan TN, Lynn MJ, et al.: Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology 2007, 69:2063–2068.CrossRefPubMedGoogle Scholar
  23. 23.
    Arenillas JF, Molina CA, Chacon P, et al.: High lipoprotein (a), diabetes, and the extent of symptomatic intracranial atherosclerosis. Neurology 2004, 63:27–32.PubMedGoogle Scholar
  24. 24.
    Reichard P, Nilsson BY, Rosenqvist U: The effect of longterm intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 1993, 329:304–309.CrossRefPubMedGoogle Scholar
  25. 25.
    Ohkubo Y, Kishikawa H, Araki E, et al.: Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995, 28:103–117.CrossRefPubMedGoogle Scholar
  26. 26.
    Stamler J, Vaccaro O, Neaton JD, Wentworth D: Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993, 16:434–444.CrossRefPubMedGoogle Scholar
  27. 27.
    Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998, 352:837–853.Google Scholar
  28. 28.
    Suwanwela NC, Chutinet A, Phanthumchinda K: Inflammatory markers and conventional atherosclerotic risk factors in acute ischemic stroke: comparative study between vascular disease subtypes. J Med Assoc Thai 2006, 89:2021–2027.PubMedGoogle Scholar
  29. 29.
    Kostner GM, Marth E, Pfeiffer KP, Wege H: Apolipoproteins AI, AII and HDL phospholipids but not APO-B are risk indicators for occlusive cerebrovascular disease. Eur Neurol 1986, 25:346–354.CrossRefPubMedGoogle Scholar
  30. 30.
    Kawachi I, Colditz GA, Stampfer MJ, et al.: Smoking cessation and decreased risk of stroke in women. JAMA 1993, 269:232–236.CrossRefPubMedGoogle Scholar
  31. 31.
    Wolf PA, D’Agostino RB, Kannel WB, et al.: Cigarette smoking as a risk factor for stroke. The Framingham Study. JAMA 1988, 259:1025–1029.CrossRefPubMedGoogle Scholar
  32. 32.
    Mast H, Thompson JL, Lin IF, et al.: Cigarette smoking as a determinant of high-grade carotid artery stenosis in Hispanic, black, and white patients with stroke or transient ischemic attack. Stroke 1998, 29:908–912.PubMedGoogle Scholar
  33. 33.
    Sacco RL, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Stroke 2006, 37:577–617.CrossRefPubMedGoogle Scholar
  34. 34.
    Park JH, Kwon HM, Roh JK: Metabolic syndrome is more associated with intracranial atherosclerosis than extracranial atherosclerosis. Eur J Neurol 2007, 14:379–386.CrossRefPubMedGoogle Scholar
  35. 35.
    Bang OY, Kim JW, Lee JH, et al.: Association of the metabolic syndrome with intracranial atherosclerotic stroke. Neurology 2005, 65:296–298.CrossRefPubMedGoogle Scholar
  36. 36.
    Ovbiagele B, Saver JL, Lynn MJ, et al.: Impact of metabolic syndrome on prognosis of symptomatic intracranial atherostenosis. Neurology 2006, 66:1344–1349.CrossRefPubMedGoogle Scholar
  37. 37.
    Chimowitz MI, Kokkinos J, Strong J, et al.: The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995, 45:1488–1493.PubMedGoogle Scholar
  38. 38.
    Kwon SU, Cho YJ, Koo JS, et al.: Cilostazol prevents the progression of the symptomatic intracranial arterial stenosis: the multicenter double-blind placebo-controlled trial of cilostazol in symptomatic intracranial arterial stenosis. Stroke 2005, 36:782–786.CrossRefPubMedGoogle Scholar
  39. 39.
    Sundt TM Jr, Smith HC, Campbell JK, et al.: Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc 1980, 55:673–680.PubMedGoogle Scholar
  40. 40.
    Connors JJ 3rd, Wojak JC: Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg 1999, 91:415–423.CrossRefPubMedGoogle Scholar
  41. 41.
    Qureshi AI: Ten years of advances in neuroendovascular procedures. J Endovasc Ther 2004, 11(Suppl 2):II1–II4.PubMedGoogle Scholar
  42. 42.
    Taylor RA, Kasner SE: Treatment of intracranial arterial stenosis. Expert Rev Neurother 2006, 6:1685–1694.CrossRefPubMedGoogle Scholar
  43. 43.
    Fiorella D, Chow MM, Anderson M, et al.: A 7-year experience with balloon-mounted coronary stents for the treatment of symptomatic vertebrobasilar intracranial atheromatous disease. Neurosurgery 2007, 61:236–242.CrossRefPubMedGoogle Scholar
  44. 44.
    Siddiq F, Vazquez G, Memon MZ, et al.: Comparison of primary angioplasty with stent placement for treating symptomatic intracranial atherosclerotic diseases: a multicenter study. Stroke 2008, 39:2505–2510.CrossRefPubMedGoogle Scholar
  45. 45.
    Bose A, Hartmann M, Henkes H, et al.: A novel, selfexpanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke 2007, 38:1531–1537.CrossRefPubMedGoogle Scholar
  46. 46.
    Fiorella D, Levy EI, Turk AS, et al.: US multicenter experience with the Wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 2007, 38:881–887.CrossRefPubMedGoogle Scholar
  47. 47.
    Zaidat OO, Klucznik R, Alexander MJ, et al.: The NIH registry on use of the Wingspan stent for symptomatic 70–99% intracranial arterial stenosis. Neurology 2008, 70:1518–1524.CrossRefPubMedGoogle Scholar
  48. 48.
    Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. N Engl J Med 1985, 313:1191–1200.Google Scholar
  49. 49.
    Schoenhagen P, Tuzcu EM, Apperson-Hansen C, et al.: Determinants of arterial wall remodeling during lipid-lowering therapy: serial intravascular ultrasound observations from the Reversal of Atherosclerosis with Aggressive Lipid Lowering Therapy (REVERSAL) trial. Circulation 2006, 113:2826–2834.CrossRefPubMedGoogle Scholar
  50. 50.
    Nissen SE, Nicholls SJ, Sipahi I, et al.: Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA 2006, 295:1556–1565.CrossRefPubMedGoogle Scholar
  51. 51.
    Mack CA, Patel SR, Schwarz EA, et al.: Biologic bypass with the use of adenovirus-mediated gene transfer of the complementary deoxyribonucleic acid for vascular endothelial growth factor 121 improves myocardial perfusion and function in the ischemic porcine heart. J Thorac Cardiovasc Surg 1998, 115:168–176.CrossRefPubMedGoogle Scholar
  52. 52.
    Stewart DJ, Hilton JD, Arnold JM, et al.: Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF(121) (AdVEGF121) versus maximum medical treatment. Gene Ther 2006, 13:1503–1511.CrossRefPubMedGoogle Scholar
  53. 53.
    Liebeskind DS: Collateral therapeutics for cerebral ischemia. Exp Rev Neurother 2004, 4:255–265.CrossRefGoogle Scholar
  54. 54.
    Shikhaliev PM, Xu T, Ducote JL, et al.: Positron autoradiography for intravascular imaging: feasibility evaluation. Phys Med Biol 2006, 51:963–979.CrossRefPubMedGoogle Scholar
  55. 55.
    Larose E, Yeghiazarians Y, Libby P, et al.: Characterization of human atherosclerotic plaques by intravascular magnetic resonance imaging. Circulation 2005, 112:2324–2331.CrossRefPubMedGoogle Scholar
  56. 56.
    Wainstein M, Costa M, Ribeiro J, et al.: Vulnerable plaque detection by temperature heterogeneity measured with a guidewire system: clinical, intravascular ultrasound and histopathologic correlates. J Invasive Cardiol 2007, 19:49–54.PubMedGoogle Scholar
  57. 57.
    Lindner JR: Evolving applications for contrast ultrasound. Am J Cardiol 2002, 90:72J–80J.CrossRefPubMedGoogle Scholar

Copyright information

© Current Medicine Group, LLC 2009

Authors and Affiliations

  1. 1.Zeenat Qureshi Stroke Research Center, Department of NeurologyUniversity of MinnesotaMinneapolisUSA

Personalised recommendations