Muristek
Intracranial atherosclerosis (ICAS) is a major cause of stroke worldwide. Although approximately 12% of White patients with a history of acute ischemic stroke or transient ischemic attack (TIA) have some form of ICAS detected on routine screening in predominantly older adults, ICAS accounts for an estimated up to one-third of ischemic strokes in Black, Asian, and Hispanic populations at comparatively younger ages. The reasons for these differences are not clear, because risk factor profiles are broadly similar across racial and ethnic groups. ICAS presents diagnostic challenges, not just in differentiating this condition from other causes of stroke or TIA (including nonatherosclerotic conditions such as moyamoya disease, arterial dissection, and intracranial vasculitis), but also in defining underlying mechanisms of ischemia in those with ICAS (eg, artery-to-artery embolism, in situ thrombotic occlusion of large vessels, local branch occlusion of small perforating vessels, hemodynamic insufficiency), which influence prognosis and treatment. Considering the need to balance potential benefits with the risks of reperfusion treatment (both for the acute ischemic stroke event and in elective stenting for secondary prevention) along with appropriate use of antiplatelet therapy, the treatment of patients with ICAS can be complex. These complexities have been reiterated by the neutral results of 2 investigator-initiated and -conducted, multicenter clinical trials undertaken in China, published in this issue of JAMA.
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