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Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 246-247

Intracranial atherosclerosis disease: A preventable epidemic

Professor of Neurology and Psychiatry, Director of Stroke Services and Fellowship Program, UMass Memorial Medical Center, Worcester, Massachusetts; Director of Stroke and Sleep Programs, Day Kimball Hospital, Putnam Connecticut, Putnam, CT, USA

Date of Submission11-Feb-2020
Date of Acceptance12-Feb-2020
Date of Web Publication10-Jun-2020

Correspondence Address:
Dr. Majaz Moonis
Professor of Neurology and Psychiatry, University of Massachusetts Medical School and UMass Memorial medical Center, 55 Lake Avenue North, Worcester, Massachusetts, 01655
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aian.AIAN_82_20

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How to cite this article:
Moonis M. Intracranial atherosclerosis disease: A preventable epidemic. Ann Indian Acad Neurol 2020;23:246-7

How to cite this URL:
Moonis M. Intracranial atherosclerosis disease: A preventable epidemic. Ann Indian Acad Neurol [serial online] 2020 [cited 2021 Nov 27];23:246-7. Available from:

   Intracranial Atherosclerotic Disease: A Preventable Epidemic Top

Intracranial atherosclerotic disease (ICAD) is a common cause of acute ischemic stroke (AIS). There is a higher prevalence in the Asian, Black, and Hispanic population. Population studies suggest that the South Asians have the highest prevalence.[1]

A common factor related to these different groups is the lack of awareness and participation in primary prevention programs. Preventable risk factors are often recognized after the incident stroke or other vascular events.

The major risk factors related with ICAD include diabetes mellitus (DM), hypertension (HTN), metabolic syndrome, hyperlipidemia, sedentary lifestyle, and smoking.[2] The South Asian dietary habits had been discussed as a cause of the high incidence of DM.[3],[4]

Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial (SAMMPRIS) demonstrated that aggressive management of the risk factors [dual antiplatelet treatment with aspirin and clopidogrel (DAPT) for 3 months, high-dose statins, control of DM and HTN, and life-style modification] reduced recurrent ischemic stroke and was superior to management with added stenting of the symptomatic intracranial artery (absolute benefit of 8.9%). This benefit persisted up until 3 years of follow-up (7.1%, 6.9%, and 9%). Warfarin Aspirin in Symptomatic Intracranial Disease (WASID) trial that compared aspirin with therapeutic warfarin anticoagulation in symptomatic intracranial stenosis greater than 50% was stopped prematurely. There was a clear superiority of aspirin over warfarin. Comparison of the control arm (Aggressive medical management alone) of SAMMPRIS to the aspirin arm of WASID revealed a greater benefit of the aggressive medical management of the risk factors over aspirin alone.[5],[6]

In this comparative analysis, the authors report the differences seen in 2 different populations with ICAD, namely, from Kerala, India and Chicago, United States. The authors provide some insights to the contributing demographics, risk factors, stroke outcomes, and recurrent strokes related to ICAD.[7]

The Kerala cohort was homogenous as compared to the heterogeneous Chicago population. Although the risk factors were not different between the populations, Indian patients were younger and had more severe incident stroke with a higher prevalence of DM. The 3-month outcomes of recurrent ischemic strokes (RIS) were lower in the Indian population possibly because of the significantly higher use of dual antiplatelet therapy (DAPT) and statins. This is consistent with the existing data on stroke prevention in symptomatic ICAD.[6] Interestingly, recurrent transient ischemic attacks (TIA) were higher despite DAPT.[8] Timing of initiation of statins and DAPT was not factored in the analysis. Statin use in improving stroke outcomes is related to whether patients were on statins prior to AIS or statin initiation after stroke onset. Statin naive patients seem to derive maximum benefit, especially if they are started within the first 72 h of stroke onset.[9]

Although primary prevention exists in the United States, it is underutilized by the population at risk. Organized prevention programs are sparse and non-existent in the rural and semi-urban regions of India.

The results of this study reinforce the need for these much-needed prevention programs. Increasing awareness and early recognition and management of risk factors, especially diabetes and hyperlipidemia must be the first step in reducing ICAD-related strokes in this high-risk population.

   References Top

Holmstedt CA, Turan TN, Chimowitz MI. Atherosclerotic intracranial arterial stenosis: Risk factors, diagnosis, and treatment. Lancet Neurol 2013;12:1106-14.  Back to cited text no. 1
Lei C, Wu B, Liu M, Chen Y. Risk factors and clinical outcomes associated with intracranial and extracranial atherosclerotic stenosis acute ischemic stroke. J Stroke Cerebrovasc Dis 2014;23:1112-7.  Back to cited text no. 2
Kapoor D, Iqbal R, Singh K, Jaacks LM, Shivashankar R, Sudha V, et al. Association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among adults in South Asia: The CARRS study. Asia Pac J Clin Nutr 2018;27:1332-43.  Back to cited text no. 3
Sohal T, Sohal P, King-Shier KM, Khan NA. Barriers and facilitators for type-2 diabetes management in South Asians: A systematic review. PLoS One 2015;10:e0136202.  Back to cited text no. 4
Chaturvedi S, Turan TN, Lynn MJ, Derdeyn CP, Fiorella D, Janis LS, et al. Do patient characteristics explain the differences in outcome between medically treated patients in SAMMPRIS and WASID? Stroke 2015;46:2562-7.  Back to cited text no. 5
Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. 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;383:333-41.  Back to cited text no. 6
Saraf U PS, Arun K, Babiker, Rajendran A, Kesavadas C, Sylaja PN. Comparison of risk factors, treatment, and outcome in patients with symptomatic intracranial atherosclerotic disease in India and the United States. Ann Indian Acad Neurol 2020:[In this issue].  Back to cited text no. 7
  [Full text]  
Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, et al. Outcomes associated with clopidogrel-aspirin use in minor stroke or transient ischemic attack: A pooled analysis of clopidogrel in high-risk patients with acute non-disabling cerebrovascular events (CHANCE) and platelet-oriented inhibition in New TIA and minor ischemic stroke (POINT) Trials. JAMA JAMA Neurol. 2019 Aug 19. doi: 10.1001/jamaneurol. 2019.2531. [Epub ahead of print] Erratum in: JAMA Neurol. 2019  Back to cited text no. 8
Flint AC, Conell C, Ren X, Kamel H, Chan SL, Rao VA, et al. Statin adherence is associated with reduced recurrent stroke risk in patients with or without atrial fibrillation. Stroke 2017;48:1788-94.  Back to cited text no. 9


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