Given the prevalence and impact of ICAD on neurological disability, developing effective treatment for ICAD represents a key goal in sustaining brain health. Brain or cerebrovascular health is a relatively novel concept, unlike the established prominence of cardiovascular health. Despite this public health priority, there remain no proven treatments for acute or recurrent ischemia due to ICAD ( 4). Furthermore, recurrent ischemia may not cause clinical stroke events, yet cognitive and other neurological impairment may ensue ( 3). The neurological impact of ICAD is likely vastly underestimated by the incidence of recurrent stroke, as relatively mild clinical severity, involvement of secondary or less apparent functional regions of the brain and lack of continuity of care decrease reported recurrent events. As the most common etiology of ischemic stroke, effective treatment strategies for acute ischemia and secondary stroke prevention are greatly needed. Recurrent stroke due to intracranial atherosclerotic disease (ICAD), the leading cause of stroke worldwide, causes an overwhelming burden of disability ( 1, 2). The evolving science of multivariable interactions in ICAD and use of big data are explored, followed by an overview of recently launched clinical trials. The temporal features of ICAD and longitudinal observation are considered with respect to management and risk factor modification.
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Imaging correlates are reviewed, from routine multimodal CT or MRI to advanced angiographic techniques. This thematic overview provides perspective on current definitions for arterial stenosis, symptomatic lesions and outcomes or endpoints in clinical trials. The ICAS 2019 meeting provided a roadmap for accelerating global innovation, underscoring the epidemiology, prior scientific evidence from trials, diagnostic tools or imaging, novel biomarkers, management approaches, and a broad range of treatments including many new medications, endovascular, and surgical strategies. Theranostics for ICAD incorporates an integrated diagnostic and therapeutic approach tailored to a specific individual. Challenges and concrete initiatives have emerged in the implementation of precision medicine for ICAD, focusing personalized treatment for the prevention of stroke and cognitive impairment around pathophysiology.
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