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Secondary stroke prevention: challenges and solutions.

Esenwa C, Gutierrez J - Vasc Health Risk Manag (2015)

Bottom Line: In the case of symptomatic extracranial carotid stenosis, surgical intervention as close as possible in time to the index event seems highly beneficial.In the case of intracranial large artery atherosclerosis, the best medical therapy consists of antiplatelets, high-dose statins, aggressive controls of vascular risk factors, and lifestyle modifications, with no role for intracranial arterial stenting or angioplasty.For patients with small artery occlusion (ie, lacunar stroke), the therapy is similar to that used in patients with intracranial large artery atherosclerosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA.

ABSTRACT
Stroke is the leading cause of disability in the USA and a major cause of mortality worldwide. One out of four strokes is recurrent. Secondary stroke prevention starts with deciphering the most likely stroke mechanism. In general, one of the main goals in stroke reduction is to control vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking cessation. Changes in lifestyle like a healthy diet and aerobic exercise are also recommended strategies. In the case of cardioembolism due to atrial fibrillation, mechanical valves, or cardiac thrombus, anticoagulation is the mainstay of therapy. The role of anticoagulation is less evident in the case of bioprosthetic valves, patent foramen ovale, and dilated cardiomyopathy with low ejection fraction. Strokes due to larger artery atherosclerosis account for approximately a third of all strokes. In the case of symptomatic extracranial carotid stenosis, surgical intervention as close as possible in time to the index event seems highly beneficial. In the case of intracranial large artery atherosclerosis, the best medical therapy consists of antiplatelets, high-dose statins, aggressive controls of vascular risk factors, and lifestyle modifications, with no role for intracranial arterial stenting or angioplasty. For patients with small artery occlusion (ie, lacunar stroke), the therapy is similar to that used in patients with intracranial large artery atherosclerosis. Despite the constant new evidence on how to best treat patients who have suffered a stroke, the risk of stroke recurrence remains unacceptably high, thus evidencing the need for novel therapies.

No MeSH data available.


Related in: MedlinePlus

Stroke and intracranial atherosclerosis.Notes: A woman in her 60s came to the hospital for left-sided weakness and headache. On exam, she was found to have mild left pronator drift and visuospatial neglect. (A) The brain magnetic resonance image showed evidence of a right parietal lobe cortical infarct and (B) the brain magnetic resonance angiograph showed evidence of diffuse luminal narrowing of her brain arteries (arrows), with some of these stenoses located proximal to the area of her infarction (small arrow), suggesting artery-to-artery embolism from intracranial large artery stenosis as the most likely stroke mechanism.
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f2-vhrm-11-437: Stroke and intracranial atherosclerosis.Notes: A woman in her 60s came to the hospital for left-sided weakness and headache. On exam, she was found to have mild left pronator drift and visuospatial neglect. (A) The brain magnetic resonance image showed evidence of a right parietal lobe cortical infarct and (B) the brain magnetic resonance angiograph showed evidence of diffuse luminal narrowing of her brain arteries (arrows), with some of these stenoses located proximal to the area of her infarction (small arrow), suggesting artery-to-artery embolism from intracranial large artery stenosis as the most likely stroke mechanism.

Mentions: Stroke attributed to LAA is defined as infarction distal to a large vessel stenosis. Frequent sites for atherosclerotic plaques include the aortic arch and ascending aorta, the extracranial carotid artery, and the proximal arteries in the Circle of Willis (Figures 1 and 2).12–14 Ischemia most commonly results from distal embolization of thrombotic products, a so-called artery-to-artery embolism, but it can also be caused by hypoperfusion of brain tissue distal to a severely stenotic or occluded vessel or from branch occlusive disease (Figures 1–3).


Secondary stroke prevention: challenges and solutions.

Esenwa C, Gutierrez J - Vasc Health Risk Manag (2015)

Stroke and intracranial atherosclerosis.Notes: A woman in her 60s came to the hospital for left-sided weakness and headache. On exam, she was found to have mild left pronator drift and visuospatial neglect. (A) The brain magnetic resonance image showed evidence of a right parietal lobe cortical infarct and (B) the brain magnetic resonance angiograph showed evidence of diffuse luminal narrowing of her brain arteries (arrows), with some of these stenoses located proximal to the area of her infarction (small arrow), suggesting artery-to-artery embolism from intracranial large artery stenosis as the most likely stroke mechanism.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4536764&req=5

f2-vhrm-11-437: Stroke and intracranial atherosclerosis.Notes: A woman in her 60s came to the hospital for left-sided weakness and headache. On exam, she was found to have mild left pronator drift and visuospatial neglect. (A) The brain magnetic resonance image showed evidence of a right parietal lobe cortical infarct and (B) the brain magnetic resonance angiograph showed evidence of diffuse luminal narrowing of her brain arteries (arrows), with some of these stenoses located proximal to the area of her infarction (small arrow), suggesting artery-to-artery embolism from intracranial large artery stenosis as the most likely stroke mechanism.
Mentions: Stroke attributed to LAA is defined as infarction distal to a large vessel stenosis. Frequent sites for atherosclerotic plaques include the aortic arch and ascending aorta, the extracranial carotid artery, and the proximal arteries in the Circle of Willis (Figures 1 and 2).12–14 Ischemia most commonly results from distal embolization of thrombotic products, a so-called artery-to-artery embolism, but it can also be caused by hypoperfusion of brain tissue distal to a severely stenotic or occluded vessel or from branch occlusive disease (Figures 1–3).

Bottom Line: In the case of symptomatic extracranial carotid stenosis, surgical intervention as close as possible in time to the index event seems highly beneficial.In the case of intracranial large artery atherosclerosis, the best medical therapy consists of antiplatelets, high-dose statins, aggressive controls of vascular risk factors, and lifestyle modifications, with no role for intracranial arterial stenting or angioplasty.For patients with small artery occlusion (ie, lacunar stroke), the therapy is similar to that used in patients with intracranial large artery atherosclerosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA.

ABSTRACT
Stroke is the leading cause of disability in the USA and a major cause of mortality worldwide. One out of four strokes is recurrent. Secondary stroke prevention starts with deciphering the most likely stroke mechanism. In general, one of the main goals in stroke reduction is to control vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking cessation. Changes in lifestyle like a healthy diet and aerobic exercise are also recommended strategies. In the case of cardioembolism due to atrial fibrillation, mechanical valves, or cardiac thrombus, anticoagulation is the mainstay of therapy. The role of anticoagulation is less evident in the case of bioprosthetic valves, patent foramen ovale, and dilated cardiomyopathy with low ejection fraction. Strokes due to larger artery atherosclerosis account for approximately a third of all strokes. In the case of symptomatic extracranial carotid stenosis, surgical intervention as close as possible in time to the index event seems highly beneficial. In the case of intracranial large artery atherosclerosis, the best medical therapy consists of antiplatelets, high-dose statins, aggressive controls of vascular risk factors, and lifestyle modifications, with no role for intracranial arterial stenting or angioplasty. For patients with small artery occlusion (ie, lacunar stroke), the therapy is similar to that used in patients with intracranial large artery atherosclerosis. Despite the constant new evidence on how to best treat patients who have suffered a stroke, the risk of stroke recurrence remains unacceptably high, thus evidencing the need for novel therapies.

No MeSH data available.


Related in: MedlinePlus