Severe stenosis of cerebral blood vessels: how long is aspirin combined with clopidogrel orally?

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

Symptomatic intracranial arterial stenosis is defined as 50% to 99% stenosis of large intracranial arteries, and the stenosis of responsible arteries leads to TIA or ischemic stroke. Intracranial segment of internal artery, basilar artery and intracranial segment of vertebral artery.

The American Association of Neurology (AAN) publishes Practice Guidelines for Stroke Prevention in Symptomatic Intracranial Atherosclerotic Stenosis online in Neurology, March 2022 , all dry goods! Let’s learn together!

Clinical Practice Recommendations:


Recommendation 1: Clinicians should combine imaging and other information to diagnose sICAS, and distinguish other intracranial vascular causes, because the clinical management and prognosis of different intracranial vascular conditions are not Not the same (Grade B).

Antithrombotic therapy

1) Clinical question: What is the difference between anticoagulation and antiplatelet therapy for sICAS?

Research Evidence: The WASID Study.

Recommendation 2: For patients with sICAS, aspirin 325 mg/day is superior to warfarin in preventing long-term stroke recurrence and death (Grade B).

2) Clinical question: Which antiplatelet regimen reduces long-term risk of stroke recurrence and death in patients with sICAS?

Research evidence: SAMMPRIS study, CLAIR study, CHANCE study.

Recommendation 3: For ischemic stroke patients with severe stenosis (70%-99%) sICAS and a low risk of hemorrhagic transformation, aspirin combined with chlorine is recommended. Pidogrel 75 mg/d for 90 days (Grade B).

3) Clinical Question: What is the role of cilostazol in secondary prevention of sICAS?

Research evidence: TOSS study, TOSS-2 study, CATHARSIS study, CSPS study.

Recommendation 4: For patients with sICAS and lower risk of hemorrhagic transformation, aspirin can be combined with cilostazol 200 mg/d for 90 days, to reduce the risk of stroke recurrence. However, cilostazol is currently only used as a substitute for clopidogrel resistance or in Asian populations (Grade C).

Risk Factor Control

Clinical question: The target value of blood lipid and blood pressure management in sICAS secondary prevention management?

Research evidence: WASID study, SAMMPRIS study, CICAS study.

Recommendation 5: It is recommended that high-intensity statin therapy be used in patients with sICAS, with a target low-density lipoprotein LDL of 70 mg/dL (1.8 mmol/L )the following.

Recommendation 6: For sICAS patients with stable disease, it is recommended that the long-term blood pressure target be reduced to less than 140/90 mmHg.

Physical activity

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

Other risk factor controls

Recommendation 8: If sICAS patients have other modifiable risk factors for cerebrovascular disease (such as smoking, diabetes, etc., editor’s note), strict intervention must be undertaken, to reduce the risk of stroke and recurrence of vascular events (Grade A).

Ischemic preconditioning of both upper extremities

Recommendation 9: Whether patients with sICAS should use ischemic preconditioning for both upper extremities, there is no consensus among experts.

Endovascular Therapy

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

Research evidence: SAMMPRIS study, VISSIT study.

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

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

Recommendation 12: Except in clinical studies, angioplasty alone is not routinely recommended for secondary prevention in patients with sICAS (Grade B).

Recommendation 13: When a PTAS program is implemented, clinicians should adequately inform patients about the risks and alternatives to PTAS treatment (Grade B).

Surgical treatment

Clinical Question: Does Surgical Bypass Reduce the Risk of Recurrent Stroke in sICAS Patients?

Research Evidence: The COSS Study.

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

Recommendation 15: The routine use of indirect surgical revascularization (eg, brain-dural-arterial revascularization EDAS, ed. Note) Prevention of sICAS stroke recurrence (Grade A).

The diagnosis and treatment of patients with symptomatic intracranial arterial stenosis still faces many problems that need to be solved. In the future, continuous research is still needed to clarify the optimal drug treatment plan (such as the type of antithrombotic therapy) and duration), explore safer and more durable endovascular treatment techniques and materials, and at the same time need to discover clinical, genetic and imaging markers to identify high-risk sICAS patients, we look forward to it together!

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