Practical approach to management of intracranial atherosclerosis.

opinion statementIntracranial atherosclerosis (ICAS) is one of the most frequent causes of stroke worldwide and has a high incidence of recurrent stroke. The therapeutic approaches for treating this high-risk disease have been evolving over time. The most recent, evidence-based approach is to focus on aggressive medical management of vascular risk factors and includes short-term dual antiplatelet treatment for 90 days followed by antiplatelet monotherapy. The role of endovascular therapy in the treatment of ICAS has not been established and is currently reserved only for patients who have failed aggressive medical management with recurrent ischemic events. There are no currently recommended surgical options to treat ICAS; however, investigational treatments such as encephaloduroarteriosynagiosis (EDAS) may hold promise. Despite aggressive medical management with short-term dual antiplatelet therapy, there remains a subset of patients with severe ICAS who will have recurrence of ischemic events. Further research is needed to better identify this high-risk subset and develop novel treatments to prevent further stroke and death.