Imaging and Clinical Predictors of Unfavorable Outcome in Medically Treated Symptomatic Intracranial Atherosclerotic Disease Mahesh Kate, MD, DM, Padmavathy N. Sylaja, MD, DM, Chandrasekharan Kesavadas, MD, and Bejoy Thomas, MD Background: Patients with symptomatic intracranial atherosclerotic disease (sICAD) have an increased risk of stroke and vascular death. The aim of the study was to eval- uate the natural history and outcome of patients with sICAD treated medically. Methods: The study population was first-ever transient ischemic attack (TIA) or stroke patients presenting to our institute who on vascular imaging had isolated intracranial atherosclerosis as cause of their symptoms and have a follow-up of 90 days. Unfavorable outcome was defined as occurrence of TIA, stroke, acute cor- onary event, and/or vascular death. Results: Fifty-three (11.8%) of the 449 ischemic stroke patients had sICAD. The risk of stroke in sICAD was 8.9%, 11.1%, 13.3%, and 15.6% in first 7 days, 30 days, 90 days, and 1 year, respectively. Five (11.1%) had car- diovascular events and accounted for 50% of mortality. The predictors of unfavor- able outcome were presented as limb weakness (85.7% versus 58.8%, hazard ratio 1.5; 95% confidence interval [CI], .05-.9; P 5.04), National Institutes of Health Stroke Scale (NIHSS) score 8 at admission (50% versus 5.9%, hazard ratio 8.5; 95% CI, .007- .5; P 5 .02), magnetic resonance imaging (MRI) with multiple diffusion-weighted imaging (DWI) lesions (65.4% versus 26.7%; 95% CI, .04-.7; P 5 .01), and angiogra- phy suggestive of diffuse atherosclerosis (50% versus 11.8%; 95% CI, odds ratio .02-.7; P 5.009). On stepwise multiple regression, variables for unfavorable outcome were NIHSS score of 8 or more at admission (P 5 .001), multiple DWI lesion on MRI (P 5.04), and diffuse atherosclerosis on angiography (P 5.006). Conclusion: The pa- tients with sICAD have a high risk of stroke and cardiac events even on aggressive medical treatment. Clinical and imaging features can identify this high-risk group. Key Words: Intracranial atherosclerotic disease—predictors—stroke— intracranial stenosis—treatment—TIA. Ó 2013 by National Stroke Association Introduction Intracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke, accounting for 8%-50% of pa- tients, 1 with higher incidence and prevalence in the Asian as compared with the Caucasian population. 1,2 Following the stenting versus aggressive medical therapy for intracranial arterial stenosis (SAMMPRIS) study, the present consensus opinion recommends medical management with dual antiplatelet agents for 90 days followed by aspirin and aggressive control of risk factors including hypertension, diabetes, smoking, and dyslipidemia. 3 The annual recurrent stroke or From the Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India. Received June 29, 2013; revision received August 6, 2013; accepted August 9, 2013. There is no conflict of interest, and the study has received ethics ap- proval. Address correspondence to Padmavathy N. Sylaja, MD, DM, Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India. E-mail: sylajapn@hotmail.com. 1052-3057/$ - see front matter Ó 2013 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.08.002 Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2013: pp 1-6 1