AAN GUIDELINES Bundle

Key Points Treatment Diagnosis Treatment ➤ Over the last 2 decades, evidence has accumulated informing the treatment of symptomatic intracranial atherosclerotic arterial stenosis (s-ICAS) with 2 general approaches emerging: 1. aggressive medical management with dual antiplatelet therapy plus intensive control of vascular risk factors, and 2. medical therapy plus endovascular procedures. ➤ Given the high risk of recurrent stroke reported in many studies, clinical trials also focused on identifying and quantifying modifiable and non-modifiable risk factors that may place patients at a particularly high risk of recurrent stroke. ➤ Knowledge of predictors of recurrent stroke is crucial for risk stratification, effect modification, and identifying therapeutic targets in future clinical trials. ➤ Clinicians should utilize diagnostic modalities to diagnose s-ICAS and distinguish it from other intracranial vasculopathies if the results would be expected to change management or provide important prognostic information (Level B). ➤ Clinicians should recommend aspirin 325 mg/d over warfarin for long-term prevention of stroke and death in patients with s-ICAS (Level B). ➤ Clinicians 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%) s-ICAS who have low risk of hemorrhagic transformation of ischemic stroke (Level B). ➤ Clinicians may recommend adding cilostazol 200 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with s-ICAS and low risk of hemorrhagic complications as an alternative to clopidogrel or in Asian patients (Level C). ➤ Clinicians should recommend high-intensity a goal low-density lipoprotein (LDL) s-ICAS to reduce the risk of recurrent (Level B). ➤ Clinicians should recommend a <140/90 mm Hg in clinically stable the risk of recurrent stroke and ➤ Clinicians should recommend at patients with s-ICAS who are safely the risk of recurrent stroke and ➤ Clinicians must recommend treatment risk factors in patients with s-ICAS stroke and vascular events (Level ➤ The authors could not achieve consensus bilateral arm ischemic preconditioning s-ICAS. ➤ Clinicians should NOT recommend angioplasty and stenting (PTAS) prevention in patients with severe ➤ Clinicians should NOT recommend patients with moderate (50%–69%) ➤ Clinicians should NOT routinely stroke prevention in patients with (Level B). ➤ Clinicians should counsel patients and alternative treatments if one contemplated (Level B). ➤ Clinicians should NOT recommend prevention in patients with s-ICAS ➤ Clinicians must NOT routinely recommend revascularization for stroke prevention outside clinical trials (Level A).

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