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
- Stroke Service, Department of Neurology
- A.A. Martinos Center for Biomedical Imaging, Department 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'.)
- Cote R, Barnett HJ, Taylor DW. Internal carotid occlusion: a prospective study. Stroke 1983; 14:898.
- Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J. Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors. Stroke 1997; 28:2084.
- Flemming KD, Brown RD Jr, Petty GW, et al. Evaluation and management of transient ischemic attack and minor cerebral infarction. Mayo Clin Proc 2004; 79:1071.
- Barnett HJ. Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. Neurology 1978; 28:769.
- Barnett HJ, Peerless SJ, Kaufmann JC. "Stump" on internal carotid artery--a source for further cerebral embolic ischemia. Stroke 1978; 9:448.
- EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 1985; 313:1191.
- Powers WJ, Clarke WR, Grubb RL Jr, et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA 2011; 306:1983.
- Jovin TG, Gupta R, Uchino K, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 2005; 36:2426.
- Nedeltchev K, Brekenfeld C, Remonda L, et al. Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology 2005; 237:1029.
- Coward LJ, McCabe DJ, Ederle J, et al. Long-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Stroke 2007; 38:1526.
- Jenkins JS, Patel SN, White CJ, et al. Endovascular stenting for vertebral artery stenosis. J Am Coll Cardiol 2010; 55:538.
- Stayman AN, Nogueira RG, Gupta R. A systematic review of stenting and angioplasty of symptomatic extracranial vertebral artery stenosis. Stroke 2011; 42:2212.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.
- Mohr JP, Thompson JL, Lazar RM, et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345:1444.
- Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005; 352:1305.
- Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011; 365:993.
- Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989; 25:382.
- Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev 2012; 8:54.
- Ay H, Furie KL, Singhal A, et al. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005; 58:688.
- Ay H, Benner T, Arsava EM, et al. A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System. Stroke 2007; 38:2979.
- Arsava EM, Ballabio E, Benner T, et al. The Causative Classification of Stroke system: an international reliability and optimization study. Neurology 2010; 75:1277.
- Witt BJ, Ballman KV, Brown RD Jr, et al. The incidence of stroke after myocardial infarction: a meta-analysis. Am J Med 2006; 119:354.e1.
- Homma S, Di Tullio MR, Sciacca RR, et al. Effect of aspirin and warfarin therapy in stroke patients with valvular strands. Stroke 2004; 35:1436.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S.
- Amarenco P, Davis S, Jones EF, et al. Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke 2014; 45:1248.
- 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 syndrome
- Inherited thrombophilias
- Sickle cell disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS