Secondary prevention for specific causes of ischemic stroke and transient ischemic attack
- Karen L Furie, MD, MPH
Karen L Furie, MD, MPH
- Chair and Professor of Neurology
- Alpert Medical School of Brown University
- Hakan Ay, MD
Hakan Ay, MD
- Associate Professor of Radiology
- Massachusetts General Hospital
- Harvard Medical School
This topic will review the treatment of specific causes of both transient cerebral ischemia (transient ischemic attack or TIA) and ischemic stroke where the potential cause has been identified. There will be an emphasis on secondary prevention of recurrent cerebral ischemia and other vascular events. Risk factor management, which is appropriate for all patients with ischemic stroke or TIA, is reviewed in detail elsewhere. (See "Overview of secondary prevention of ischemic stroke".)
The initial assessment of patients with cerebral ischemia and acute therapy for ischemic stroke are discussed separately. (See "Initial assessment and management of acute stroke" and "Reperfusion therapy for acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack".)
LARGE ARTERY DISEASE
Options for the secondary prevention of ischemic stroke or transient ischemic attack (TIA) caused by large artery disease include revascularization (mainly for symptomatic internal carotid artery stenosis due to atherosclerosis) and multifactorial risk reduction including treatment with antiplatelet agents, antihypertensive drugs, and statins. The role of anticoagulation in this setting is quite limited, as noted below. Patients with large artery atherothrombotic disease in anterior and posterior cerebral circulation sites other than the internal carotid artery and patients with the latter lesions who cannot undergo carotid endarterectomy benefit from antiplatelet therapy. (See "Antiplatelet therapy for secondary prevention of stroke".)
Some specific situations are discussed below for carotid disease, vertebral disease, intracranial disease, and dissection (a nonatheromatous cause).
Carotid stenosis — Carotid endarterectomy is beneficial for patients with recently symptomatic internal carotid artery atherosclerotic disease. This conclusion is based upon a number of randomized, controlled trials that have demonstrated the efficacy of endarterectomy in selected patients who have carotid atherosclerosis and symptoms such as a TIA or a nondisabling stroke. This issue is discussed separately. (See "Management of symptomatic carotid atherosclerotic disease", section on 'Carotid endarterectomy'.)
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- LARGE ARTERY DISEASE
- Carotid stenosis
- - Carotid occlusion
- Extracranial vertebral artery stenosis
- Intracranial large artery atherosclerosis
- SMALL ARTERY OCCLUSION
- CARDIOGENIC EMBOLISM
- Atrial fibrillation
- Myocardial infarction and left ventricular thrombus
- Heart failure
- Rheumatic mitral valve disease
- Other mitral and aortic valvular disease
- Prosthetic heart valves
- Infective endocarditis
- PFO and atrial septal aneurysm
- AORTIC ATHEROSCLEROSIS
- BLOOD DISORDERS
- Antiphospholipid antibody syndrome
- Inherited thrombophilias
- Sickle cell disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS