Is the future of symptomatic intracranial atherosclerotic stenosis management promising

Intracranial atherosclerotic stenosis (ICAS) is one of most common causes of stroke; it has the highest rate of recurrence compared with other aetiologies.1 ICAS is especially more prevalent among the Asians.2 The results of the Chinese Intracranial Atherosclerosis Study indicated that the prevalence of symptomatic ICAS (sICAS) is as high as 46%.1 The 1-year stroke recurrence rate with sICAS is reported to be 12.2% and 15%.3 4 We understand, the following pathological reasons could account for the high recurrence rate in sICAS. First, patients with ICAS are prone to encounter hypoperfusion haemodynamics, especially under poor collateral conditions.5 Studies on the association of blood pressure (BP) control in the acute stage and clinical outcomes are contradictory, supporting this hypothesis.6 Second, plaques in stenotic arteries are usually highly vulnerable (due to large lipid cores, thin fibrous caps and intraplaque haemorrhage).7 These plaques are prone to rupture into downstream arteries, leading to embolic stroke in the territory of the responsible artery.5 Furthermore, these patients are often comorbid with heightened risk factors strongly correlated with stroke recurrence, including hypertension, metabolic disorders, dyslipidaemia.8 Therefore, there is an urgent need to standardise assessment and management of sICAS. The treatment of sICAS nowadays primarily focuses on secondary prevention to reduce stroke recurrence. Therapeutic methods include antiplatelet therapy, interventional therapy and control of risk factors.9 Two milestone trials, the Warfarin Aspirin Symptomatic Intracranial Disease (WASID)3 Trial and the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)4 Trial aim to provide an updated strategy for clinical practice. The WASID Trial, with a double-blind, multicentre, randomised control clinical trial design, aimed to evaluate the efficacy and safety of warfarin over aspirin among patients with 50%–99% degree of ICAS. Aspirin proved to be equally efficient …