Severe cerebrovascular stenosis: how long is aspirin combined with clopidogrel, di-antagonistic orally?

Symptomatic Intracranial Atherosclerosis Stenosis (sICAS) is an important cause of stroke worldwide, with high recurrence rates and a heavy disease burden.

Symptomatic intracranial artery stenosis is defined as 50% to 99% of intracranial aortic stenosis, and the responsibility artery stenosis leads to TIA or ischemic stroke, which mainly refers to the middle cerebral artery, the intracranial segment of the internal carotid artery, the basilar artery, and the intracranial segment of the vertebral artery.

In March 2022, the American Neurological Association (AAN) published the "Practical Guide for The Prevention of Symptomatic Intracranial Atherosclerotic Stenosis Stroke" online in the journal Neurology, and it was all dry goods! Let's learn together!

Clinical Practice Recommendations:

diagnosis

Recommendation 1: Clinicians should diagnose sICAS with information such as imaging and distinguish between other intracranial vascular causes, as the clinical management and prognosis of different intracranial vascular conditions are not the same (grade B).

Antithrombotic therapy

1) Clinical questions: For sICAS, the efficacy of anticoagulation and antiplatelet therapy differs?

Research evidence: WASID study.

Recommendation 2: For patients with sICAS, aspirin 325 mg/day is superior to warfarin (grade B) for the prevention of long-term stroke recurrence and death.

2) Clinical questions: For patients with sICAS, which antiplatelet regimen reduces the risk of long-term stroke recurrence and death?

Evidence: SAMMPRIS study, CLAIR study, CHANCE study.

Recommendation 3: In patients with severe stenosis (70% to 99%) sICAS and a low risk of hemorrhagic conversion, aspirin plus clopidogrel 75 mg/day is recommended for 90 days (grade B).

3) Clinical questions: The role of cilotazole in secondary prevention of sICAS?

Evidence: TOSS study, TOSS-2 study, CATHARSIS study, CSPS study.

Recommendation 4: For patients with sICAS and a lower risk of bleeding transformation, aspirin plus cilostazole 200 mg/day for 90 days to reduce the risk of stroke recurrence. However, currently cilostazole is only used instead when clopidogrel is resistant or in Asian populations (grade C).

Risk factor control

Clinical question: Serum lipids and blood pressure management target values in sICAS secondary prevention management?

Evidence: WASID study, SAMMPRIS study, CICAS study.

Recommendation 5: High-intensity statin therapy is recommended for patients with sICAS with a target LDL of less than 70 mg/dL (1.8 mmol/L).

Recommendation 6: For patients with stable sICAS, a long-term blood pressure target of less than 140/90 mmHg is recommended.

Physical activity

Recommendation 7: For patients with sICAS who are stable and can safely complete physical activity, at least appropriate physical activity is recommended to reduce the risk of recurrence of stroke and vascular events (grade B).

Control of other risk factors

Recommendation 8: If patients with sICAS have other regulatory risk factors for cerebrovascular disease (e.g., smoking, diabetes, etc., Editor's Note), rigorous intervention is necessary to reduce the risk of recurrence of stroke and vascular events (grade A).

Ischemia pre-adaptation of both upper extremities

Recommendation 9: Experts are not on whether to use double upper extremity ischemia pre-adaptation in patients with sICAS.

Endovascular therapy

Clinical question: Does Percutaneous Transluminal Angioplasty and Stenting (PTAS) reduce the risk of recurrence and death of sICAS stroke?

Research evidence: SAMMPRIS study, VISSIT study.

Recommendation 10: PTAS is not recommended as the preferred treatment regimen (grade B) for stroke prevention in patients with severe sICAS (stenosis rate 70% to 99%).

Recommendation 11: PTAS treatment (grade B) is not recommended for patients with moderate sICAS (stenosis 50% to 69%).

Recommendation 12: In addition to clinical studies, angioplasty alone is not routinely recommended for secondary prophylaxis (grade B) in patients with sICAS.

Recommendation 13: When implementing a PTAS program, clinicians should adequately inform patients of the risks of PTAS treatment and alternatives (Grade B).

Surgical treatment

Clinical Question: Does Surgical Bypass Surgery Reduce the Risk of Stroke Recurrence in Patients with SICAS?

Research evidence: COSS studies.

Recommendation 14: Direct bypass surgery for stroke prevention (grade B) is not recommended for patients with sICAS.

Recommendation 15: Routine use of indirect surgical revascularisation (e.g., cerebral-dural-arterial revascularisation EDAS, Editor's Note) to prevent recurrence of sICAS stroke (Grade A) is not recommended except in clinical studies.

The diagnosis and treatment of patients with symptomatic intracranial artery stenosis still faces many problems that need to be solved, and in the future, it is still necessary to determine the optimal drug treatment plan (such as the type and duration of antithrombotic therapy) through continuous research, explore safer and long-lasting endovascular treatment techniques and materials, and find clinical, genetic and imaging markers that identify high-risk sICAS patients.

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