From the Emory University School of Medicine, Atlanta, GA.
Abstract
- Objective: To provide an overview of the diagnosis, clinical presentation, and management of symptomatic intracranial atherosclerotic disease (ICAD).
- Methods: Review of the current literature in the context of a clinical case.
- Results: ICAD is a common cause of ischemic strokes or transient ischemic attacks (TIAs), especially among Asian, black, and Hispanic patients. ICAD can be identified with noninvasive arterial imaging such as CT angiography, MR angiography, or transcranial Doppler ultrasound of the head when evaluating for the cause of an ischemic stroke or TIA. Aggressive medical management with dual antiplatelet therapy and lifestyle and risk factor modification has emerged as effective first-line therapy. In patients who have recurrent ischemic symptoms while on aggressive medical management, endovascular treatment can be considered.
- Conclusion: When symptomatic ICAD is identified early, aggressive medical management is effective in reducing the risk of recurrent ischemic events in this patient population.
Symptomatic intracranial atherosclerotic disease (ICAD) may represent the most common cause of ischemic stroke worldwide and the cause of approximately 8% to 10% of ischemic strokes in the United States [1–7]. It is a particularly important clinical entity due to the high recurrence rate of ischemic events in this population. The estimated recurrent stroke risk from symptomatic ICAD has been reported to be as high as 14.9% in the first year after an initial ischemic event [1].There are multiple risk factors for ICAD. Non-modifiable risk factors include race (particularly Asian, black, or Hispanic race), age, and family history of coronary artery disease or stroke; modifiable risk factors include diabetes, hypertension, and hyperlipidemia [2].
Case Study
Initial Presentation
A 78-year-old right-handed man presents to the outpatient clinic for follow-up evaluation after inpatient admission for acute ischemic stroke. The patient has an established medical history of hypertension, diabetes mellitus (diagnosed 10 years ago), dyslipidemia, and a 50 pack-year history of tobacco use.
Two weeks prior to the clinic visit, the patient presented to the emergency department (ED) via emergency medical services with right face and arm weakness and numbness and the inability to speak that had been ongoing for approximately 1 hour. The patient’s wife reported to ED providers that the patient had a similar episode 1 month prior that resolved completely in 30 to 45 minutes (and for which the patient never sought medical attention). Home medications at the time of admission included aspirin 81 mg and pravastatin 20 mg daily, both of which he takes intermittently.
The initial blood pressure was 185/76 mm Hg and blood glucose was 225 mg/dL. Initial exam was remarkable for the inability to answer orientation questions (but able to follow simple commands), forced gaze deviation to the left, right lower facial weakness, weakness in the right arm with no antigravity movement, moderately decreased sensation of the right face and arm, severe expressive aphasia, and severe dysarthria. A CT of the head without contrast showed no evidence of hemorrhage. Patient was suspected of having an acute ischemic stroke and was given intravenous tPA.