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The treatment of patients with CAA differs from that of SMM according to the presence or absence of carotid or subclavian stenosis and the natural history of the disease. In symptomatic patients, antiplatelet therapy and stenting of affected segments are recommended to minimize risk of recurrent embolism. Stroke prevention in symptomatic asymptomatic CAA is recommended to control risk of hemorrhage \[[@bib13]\]. In contrast, the need for treatment in patients with asymptomatic SMM is not established because the overall risk of thromboembolic events is low.
An important problem with acute ischemic stroke is a lack of information on how to treat patients with high carotid IMT, as the primary purpose of acute therapy is to reduce tissue damage and improve neurologic outcome. However, it has been demonstrated that non-disabling ischemic strokes are associated with a much higher incidence of early ischemic stroke recurrence and disability \[[@bib22]\]. Recently, a systematic review and meta-analysis found that the annual risk of stroke in patients with carotid high-grade IMT was 6.3% \[[@bib23]\].
Although the incidence of symptomatic CAA is low, the annual risk of ischemic stroke in patients with asymptomatic CAA is 0.8%. In one study of patients with CAA without detectable extracranial occlusive lesions, the annual rate of ischemic stroke in the CAA group was 0.88% \[[@bib24]\]. This finding indicates that CAA can be a significant and independent risk factor for stroke even in asymptomatic patients. Furthermore, since nearly 80% of ischemic strokes in patients with high-grade IMT have no identifiable extracranial occlusive lesion \[[@bib25]\], a low-dose aspirin (80 mg/day) could effectively reduce the risk of ischemic stroke.
It is unclear whether anticoagulation could be an alternative approach for stroke prevention in patients with CAA. Anticoagulant therapy in patients with CAA and a history of ischemic stroke is not approved for
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