WSO - June 2023 - 513

Mead et al.
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Table 2. (Continued)
Recommendations
In patients with ischemic stroke or TIA and carotid or vertebral artery stenosis,
intensive medical therapy (e.g. antiplatelet agents, lipid-lowering medications, blood
pressure management, and diabetes control) is recommended, regardless of whether a
revascularization procedure is done, in addition to diet, exercise, and smoking cessation
In patients with ischemic stroke or TIA and aortic arch atheroma, antiplatelet therapy is
recommended
In patients with ischemic stroke or TIA and aortic arch atheroma, a target LDLcholesterol
of 1.8 mmol/L (70 mg/dL) should be pursued with high-dose statin therapy
Intracranial atherosclerotic disease
Anticoagulation
In patients with acute ischemic stroke or TIA due to high-grade intracranial
atherosclerotic disease, the use of anticoagulants is not recommended unless there is
another indication for anticoagulation (e.g. atrial fibrillation)
Single antiplatelet therapy
In patients with ischemic stroke or TIA caused by moderate to high-grade intracranial
atherosclerotic stenosis (50-99%), aspirin 325 mg daily is recommended over oral
anticoagulation. There are no strong recommendations supporting the use of dual
antiplatelet therapy (DAPT) over single antiplatelet therapy (SAPT) in this population.
While the Stenting vs Aggressive Medical Therapy for Intracranial Arterial Stenosis
(SAMMPRIS) trial showed that DAPT is better than stenting, it did not prove that DAPT
is better than SAPT.205 A post hoc analysis of the Clopidogrel in High-Risk Patients with
Acute Non-disabling Cerebrovascular Events (CHANCE) trial showed no differences in
the beneficial effect of DAPT vs SAPT in minor stroke patients with vs without intracranial
atherosclerotic disease (ICAD).206 In the Clopidogrel Plus Aspirin Versus Aspirin Alone
for Reducing Embolization in Patients With Acute Symptomatic Cerebral or Carotid
Artery Stenosis (CLAIR) Trial, 93 of 100 patients had symptomatic ICAD. DAPT use was
associated with a 54.4% (16.4-75.1) relative risk reduction on microembolic signals on
transcranial Doppler ultrasound.207
Blood pressure management
In patients with ischemic stroke or TIA caused by moderate to high-grade intracranial
atherosclerotic stenosis (50-99%), a systolic blood pressure target of < 140 mm Hg is
recommended
Lipid-lowering agents
In patients with ischemic stroke or TIA caused by moderate to high-grade intracranial
atherosclerotic stenosis (50-99%), high-dose statin therapy is recommended
Physical activity
In patients with ischemic stroke or TIA caused by moderate to high-grade intracranial
atherosclerotic stenosis (50-99%), at least moderate physical activity is recommended
Angioplasty and stenting
In patients with ischemic stroke or TIA and moderate to high-grade intracranial
atherosclerotic stenosis (50-99%), angioplasty and stenting is not recommended. Dual
antiplatelets is an appropriate medical therapy
Antithrombotic management in non-cardioembolic stroke
Indication for antiplatelet therapy
(Continued)
International Journal of Stroke, 18(5)
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WSO - June 2023

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