COR LOE Recommendations Antithrombotic Therapy In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in prefer- ence to warfarin to reduce the risk of recurrent ischemic stroke and vascular death.335,336 In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70% 99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk.336 339 In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilat- eral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk.340 In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk.341 344 CLINICAL STATEMENTS AND GUIDELINES Kleindorfer In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the usefulness of clopidogrel alone, the combination of aspirin and dipyridam- ole, ticagrelor alone, or cilostazol alone for secondary stroke prevention is not well established. Risk Factor Management In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mmHg, high-intensity statin therapy, and at least moderate physical activity are recom- mended to prevent recurrent stroke and Angioplasty and Stenting In patients with severe stenosis (70%-99%) of a major intracranial artery and actively pro- gressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mmHg, and high- intensity statin therapy (so-called medical failures), the usefulness of angio- plasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown.350 352 3: Harm A In patients with stroke or TIA attributable to severe stenosis (70% 99%) of a major intracranial artery, angioplasty and stenting should not be performed as an initial treat- ment, even for patients who were taking an antithrombotic agent at the time of the stroke 3: Harm B-NR In patients with a stroke or TIA attributable to moderate stenosis (50% 69%) of a major intracranial artery, angioplasty or stenting is associated with excess morbidity and mortal- ity compared with medical management Other Procedures Benefit B-R In patients with stroke or TIA attributable to 50% to 99% stenosis or occlusion of a major intracranial artery, extracranial-intracra- nial bypass surgery is not recommended.361 Synopsis ICAS is a common cause of stroke worldwide with a high rate of recurrent stroke.362 Severity of stenosis is a strong predictor of risk of recurrent stroke in the ter- ritory of the stenotic artery, with 1-year rates as high as Therapeutic tri- als have demonstrated that for most patients with ICAS, antithrombotic therapy and vascular risk factor control are effective for stroke prevention. 