| Unchanged | For patients with symptomatic intracranial arterial stenosis, antiplatelet is recommended over warfarin to prevent stroke and other cardiovascular events. | I | A |
| Unchanged | For patients with IS or TIA attributable to severe symptomatic intracranial artery stenosis (70–99%) within 30 days of onset, aspirin combined with clopidogrel is recommended for 90 days, after which aspirin or clopidogrel alone can be used as a long-term secondary prevention drug. | IIa | B |
| New recommendation | For patients with TIA or non-acute IS with symptomatic intracranial or extracranial arterial stenosis (50–99%) or combined with more than two risk factors, cilostazol combined with aspirin or clopidogrel may be considered. | IIb | B |
| The results from CSPS.com indicated that for patients with non-acute stroke with moderate-to-severe intracranial or extracranial stenosis and two or more vascular risk factors (age ≥65 years, hypertension, diabetes, CKD, peripheral artery disease, history of IS, history of ischaemic heart disease, smoking), the combination of cilostazol with aspirin or clopidogrel reduced the risk of stroke recurrence compared with using aspirin or clopidogrel alone, without increasing the risk of any bleeding. However, in subgroup analysis, the combination of cilostazol and aspirin showed no significant difference in effectiveness and safety compared with aspirin monotherapy or dual antiplatelet therapy.128
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| New recommendation | For patients with non-cardioembolic minor stroke (NIHSS score ≤5) or high-risk TIA (ABCD2 score ≥4) occurring within 24 hours of onset, and with mild or greater ipsilateral intracranial arterial stenosis (stenosis rate >30%), dual antiplatelet therapy with aspirin and ticagrelor (initial dose of 180 mg, followed by 90 mg two times per day) may be an option. Switching to single antiplatelet therapy is recommended after 30 days of dual antiplatelet therapy. However, clinicians should carefully balance this treatment selection’s potential benefits and bleeding risks. | IIb | B |
| The results of the CHANCE-2 trial showed that in patients with minor stroke or high-risk TIA who carry the CYP2C19 LoF, using ticagrelor instead of clopidogrel in dual antiplatelet therapy can reduce the risk of stroke recurrence at 90 days. Subgroup analysis showed that patients with symptomatic intracranial arterial stenosis had a reduction in stroke recurrence. However, the result was not significant (HR 0.76, 95% CI 0.55 to 1.04).6 94
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| New recommendation | For symptomatic severe intracranial atherosclerotic stenosis (70–99%), percutaneous transluminal angioplasty and stenting (PTAS) should not be used as the initial treatment for such patients, even if patients are taking an antithrombotic agent at the time of stroke or TIA onset. | III | A |
| Four RCTs have compared PTAS with medical treatment to prevent stroke or TIA recurrence in patients with stroke attributable to 70–99% stenosis.129–132 However, none of these trials have found any additional benefit of stenting over medical treatment alone. |
| New recommendation | For patients with symptomatic intracranial atherosclerotic moderate stenosis (50–69%), PTAS has a higher risk of disability and death than medical treatment. Therefore, PTAS is not recommended. | III | B |
| Currently, RCTs comparing the clinical outcomes of PTAS and medical therapy in patients with asymptomatic moderate intracranial arterial stenosis (50–69%) are lacking. The risk of stroke following standard medical therapy is relatively low in patients with moderate intracranial arterial stenosis, and the perioperative risk does not vary with the degree of stenosis.133 As RCTs have not yet demonstrated significant benefits of PTAS for patients with severe stenosis, the support for PTAS in moderate stenosis is also not endorsed. |
| New recommendation | Extracranial–intracranial bypass is not recommended for patients with intracranial atherosclerotic stenosis (50–99%) or occlusion that caused stroke or TIA. | III | B |
| A multicentre RCT involved 1377 patients with recent minor stroke or TIA and compared extracranial–intracranial bypass surgery with medical treatment for severe stenosis (≥70%) of the ICA or MCA.134 The results showed that compared with the medical treatment group, patients in the bypass surgery group had a higher proportion and earlier occurrence of fatal and non-fatal strokes. |
| New recommendation | For patients with recent IS or TIA within 6 months combined with severe stenosis (70–99%) in the extracranial segment of the ipsilateral carotid artery, if the expected risk of perioperative mortality or stroke recurrence is <6%, it is recommended undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) treatment. | I | A |
| The combined analysis of the ECST, CSP and NASCET trials found that in patients with severe stenosis (70–99%) of the carotid artery, CEA had an absolute benefit of 16.0% within 5 years.135 Several large studies, such as the CREST trial, have confirmed no significant difference in the incidence of stroke between the CEA and CAS groups.136–140
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| New recommendation | For patients with recent IS or TIA within 6 months combined with moderate stenosis (50–69%) in the extracranial segment of the ipsilateral carotid artery, if the expected risk of perioperative mortality or stroke recurrence is <6%, CEA or CAS is recommended. CEA or CAS should be selected according to the patient’s condition. | I | B |
| The ECST trial did not observe substantial advantages in individuals with carotid artery stenosis ranging from 50% to 69%.135 141 Conversely, both NASCET and VA309 trials demonstrated notable and statistically significant benefits.135 142 143
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| New recommendation | CEA or CAS is not recommended for patients with <50% stenosis in the extracranial segment of the carotid artery. | III | A |
| The combined analysis of the ECST, VA309 and NASCET trials revealed that CEA showed no benefit for patients with ICA stenosis of less than 50%.141–143
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| New recommendation | For patients who meet the indications for CEA or CAS treatment, for those aged ≥70 years, CEA is recommended over CAS. If surgery is planned within 1 week after stroke onset, CEA is also recommended over CAS. | IIa | B |
| The analysis conducted by the Carotid Stenting Triallists Collaboration, which included four RCTs, found that in the age group of 65–69 years, the HR was 1.61 (95% CI 0.90 to 2.88) when comparing CAS with CEA. In the age group of 70–74 years, the HR for CAS compared with CEA was 2.09 (95% CI 1.32 to 3.32). Therefore, in patients aged 70 years and above, CEA was significantly superior to CAS in reducing the perioperative risk of stroke.144
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| New recommendation | For patients with severe stenosis (≥70%) who meet the indications for CEA or CAS treatment, if the risk of CEA is high (such as radiation-induced stenosis or restenosis after CEA), CAS is the choice of treatment. | IIa | C |
| When non-invasive imaging shows carotid artery stenosis ≥70% or DSA shows stenosis >50%, and the risk of complications from the intervention is <2%, particularly in patients with significant cardiovascular disease, CAS may be considered an alternative treatment option to CEA. | IIb | B |
| In the SAPPHIRE trial, patients with higher anatomical or physiological risk for carotid revascularisation were assigned to CEA or CAS.136 The results showed that among symptomatic patients, 16.8% of CAS patients and 16.5% of CEA patients experienced the primary endpoint events, including stroke, MI or death (p=0.95). It confirmed that CAS could reduce stroke rates and perioperative complications within 30 days after the surgery. |
| New recommendation | For patients who plan to undergo CEA or CAS, if there are no contraindications for early recanalisation, it is reasonable to proceed within 2 weeks of stroke onset. | IIa | B |
| Post hoc analysis of multiple trials has found greater benefit with CEA when surgery is performed within 2 weeks after the last non-disabling ischaemic event. Therefore, if a patient is suitable for surgery, early CEA is preferred.145
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| New recommendation | Antiplatelet, lipid-lowering and antihypertensive therapies are recommended for patients with symptomatic ICA stenosis. | I | A |
| In clinical practice, it is recommended providing antiplatelet therapy, antihypertensive treatment and statin medication for patients with symptomatic carotid artery stenosis.135 Two different lipid profile targets were compared in a recent trial focusing on patients with a recent stroke or TIA. The study found that achieving a low-density lipoprotein level below 1.8 mmol/L was associated with a reduced incidence of vascular events.146
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| New recommendation | The usefulness of extracranial–intracranial bypass for patients with carotid occlusion leading to TIA or ipsilateral IS is not well established. | IIb | B |
| In the COSS trial, the combined endpoint events of stroke and death within 30 days and ipsilateral stroke within 2 years were 21.0% in the surgical group and 22.7% in the medical treatment group.147 There was no statistically significant difference between the two groups. In the recent CMOSS trial, there was no statistically significant difference observed in the composite primary outcome between the surgical group and the medical group (8.6% vs 12.3%).148
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| New recommendation | Antiplatelet, lipid-lowering and antihypertensive therapies are recommended for patients with symptomatic vertebral artery stenosis. | I | A |
| In clinical practice, it is recommended providing antiplatelet therapy, antihypertensive treatment and statin medication for patients with symptomatic vertebral artery stenosis.145
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| New recommendation | With symptomatic extracranial vertebral atherosclerotic stenosis (50–99%), when medical treatment is ineffective, stenting may be selected in addition to the best medical management, but the effectiveness of stenting has not yet been fully confirmed. | IIb | C |
| In a combined analysis of the VAST, VIST and SAMMPRIS trials, the HR for stenting compared with medical treatment was 0.63 (95% CI 0.27 to 1.46). Therefore, no significant benefit is observed for extracranial vertebral artery stenting compared with medical treatment.145
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| New recommendation | For patients with IS or TIA caused by aortic arch atheroma, antiplatelet therapy is recommended to prevent stroke recurrence. | I | B |
| The ARCH trial compared the efficacy differences between aspirin and clopidogrel versus warfarin, but the study lacked sufficient power for the primary endpoint.149 Therefore, the comparative benefits of these two treatments remain unknown. However, in the warfarin group, there were six cases of vascular death (3.4%), while no deaths were reported in the dual antiplatelet therapy group (p=0.013). The available evidence suggests that warfarin may not provide a clear advantage over dual antiplatelet therapy. However, it remains uncertain whether dual antiplatelet therapy surpasses single antiplatelet therapy. |
| New recommendation | For patients with IS or TIA caused by aortic arch atheroma, intensive statin therapy is recommended. | I | B |
| In the ARCH study, the event rate was only 20–30% of the expected rate based on observational studies with an expected rate of >12%.149 This could be attributed to better management of risk factors in the trial compared with historical studies. During the trial, there was an average reduction of low-density lipoprotein cholesterol (LDL-C) by approximately 40 mg/dL to 83–84 mg/dL. |
| New recommendation | Stenting or surgical treatment may be considered in patients with IS or TIA with symptomatic subclavian artery stenosis (50–99%) or occlusion causing symptoms of posterior circulation ischaemia when standard medical treatment is ineffective, and there are no surgical contraindications. | IIb | C |
| Currently, there is a lack of RCTs comparing endovascular treatments and surgical revascularisation methods for subclavian atherosclerotic stenosis. Previous studies indicated that the long-term patency rate after surgical revascularisation reaches 88–95%, higher than endovascular treatments (78.1–84.5%). However, it should be noted that surgical treatment carries a higher risk of trauma and invasiveness.150–153
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| New recommendation | For patients with IS or TIA caused by stenosis of the common carotid artery or brachiocephalic trunk (50–99%), stenting or surgical treatment may be considered when medical treatment is ineffective, and there are no surgical contraindications. | IIb | C |
| Currently, there is a lack of RCTs comparing endovascular treatments and surgical revascularisation methods for atherosclerotic stenosis of the common carotid artery or brachiocephalic artery. Previous studies have shown that surgical revascularisation has a higher long-term patency rate than endovascular treatments, but it is also associated with a higher risk of trauma and invasiveness.151
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