Intracranial Atherosclerotic Disease

Synonyms:

Intracranial atherosclerotic disease ICAD a.k.a. Intracranial stenosis & intracranial atherosclerosis

Diagnosis:

Catheter angiography:
WASID intracranial stenosis criteria:

50% stenosis by WASID criteria:

  • Measure the diameter of the residual lumen
  • Measure the normal reference diameter (one of the following in descending order of preference):
    • 1 Same artery proximal to the stenosis
    • 2 Same artery distal to the stenosis
    • 3 Feeding artery
  • % stenosis= [1-(residual lumen/normal diameter)]X 100

The location has to have normal vessel segment with parallel walls free of atherosclerosis
Good interobserver and intraobserver agreements

Classification of intracranial stenosis: Mori et al

Type A: <5mm short, concentric or moderately eccentric
Type B: 5-10mm long, tubular configuration, eccentric or moderately angulated
Type C: >10mm long, tortuous configuration, angulated >90 degrees.

Sites of stenosis:
  • ICA: supraclinoid, cavernous, peterous segments
  • Anterior cerebral artery ACA, middle cerebral artery MCA, Basilar artery, posterior cerebral artery PCA

Treatment:

Optimize medical therapy:

  • Dual Antiplatelets (aspirin plus clopidogrel) for at least 3 months, then single antiplatelet agent afterwards
  • BP control <140/85mmHg
  • Cholesterol control LDL <70mg/dl
  • Smoking cessation

Angioplasty plus stenting is contraindicated for first episode [SAMMPRIS]. If recurrent, no evidence to support or refute further intervention

Related articles:

References:

  1. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ; SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011 Sep 15;365(11):993-1003. doi: 10.1056/NEJMoa1105335. Epub 2011 Sep 7.
  2. Samuels OB, et al. AJNR Am J Neuroradiol2000; 21:643–4
  3. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, Montgomery J, Nizam A, Lane BF, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Lynch JR, Zaidat OO, Rumboldt Z, Cloft HJ; Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial Investigators. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet. 2014 Jan 25;383(9914):333-41. doi: 10.1016/S0140-6736(13)62038-3. Epub 2013 Oct 26.
  4. Fiorella D, Derdeyn CP, Lynn MJ, Barnwell SL, Hoh BL, Levy EI, Harrigan MR, Klucznik RP, McDougall CG, Pride GL Jr, Zaidat OO, Lutsep HL, Waters MF, Hourihane JM, Alexandrov AV, Chiu D, Clark JM, Johnson MD, Torbey MT, Rumboldt Z, Cloft HJ, Turan TN, Lane BF, Janis LS, Chimowitz MI; SAMMPRIS Trial Investigators. Detailed analysis of periprocedural strokes in patients undergoing intracranial stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS). Stroke. 2012 Oct;43(10):2682-8. Epub 2012 Sep 13.
  5. Derdeyn CP, Fiorella D, Lynn MJ, Barnwell SL, Zaidat OO, Meyers PM, Gobin YP, Dion J, Lane BF, Turan TN, Janis LS, Chimowitz MI; SAMMPRIS Trial Investigators. Impact of operator and site experience on outcomes after angioplasty and stenting in the SAMMPRIS trial. J Neurointerv Surg. 2013 Nov;5(6):528-33. doi: 10.1136/neurintsurg-2012-010504. Epub 2012 Sep 12.
  6. Lutsep HL, Barnwell SL, Larsen DT, Lynn MJ, Hong M, Turan TN, Derdeyn CP, Fiorella D, Janis LS, Chimowitz MI; SAMMPRIS Investigators. Outcome in patients previously on antithrombotic therapy in the SAMMPRIS trial: subgroup analysis. Stroke. 2015 Mar;46(3):775-9. doi: 10.1161/STROKEAHA.114.007752. Epub 2015 Jan 15.
  7. Waters MF, Hoh BL, Lynn MJ, Kwon HM, Turan TN, Derdeyn CP, Fiorella D, Khanna A, Sheehan TO, Lane BF, Janis S, Montgomery J, Chimowitz MI; Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial Investigators. Factors Associated With Recurrent Ischemic Stroke in the Medical Group of the SAMMPRIS Trial. JAMA Neurol. 2016 Jan 4:1-8. doi: 10.1001/jamaneurol.2015.4315.