Critical Care Medicine-Neurologic Disorders>>>>>Cerebrovascular Diseases
Question 5#

A 69-year-old male, who has not seen a doctor in at least 10 years, presents to the emergency department for left-sided numbness and weakness. He initially had symptoms 1 day before presentation that lasted for 30 minutes with complete recovery. A head CT did not demonstrate any ischemic changes. A magnetic resonance imaging (MRI) did not demonstrate any infarction. A magnetic resonance angiogram (MRA) of the intracranial and neck vessels demonstrated severe stenosis of the right MCA.

What is the next best step management?

a. Consultation to endovascular service for angioplasty and placement of a stent across the right MCA stenosis
b. Start intravenous (IV) heparin infusion with bolus of heparin
c. Start dual antiplatelet therapy with aspirin and clopidogrel
d. Start single antiplatelet therapy with aspirin following a loading dose

Correct Answer is C

Comment:

Correct Answer: C

This patient presents with a crescendo transient ischemic attack (TIA), defined as recurrent episodes of TIAs over hours to as long as 1 week. The potential mechanism may be embolic or hemodynamic. There are prior studies that examine patients with stroke or TIA attributed to stenosis of 70% to 99% diameter of a major intracranial artery—SAMPRIS trial. In this trial, patients were randomized to percutaneous transluminal angioplasty and stenting with aggressive medical management versus aggressive medical management alone (aspirin and clopidogrel, management of primary and secondary risk factors including lifestyle modification). In those undergoing stenting there was increased risk of stroke and death at 30 days and 1 year compared to medical therapy alone. 

A second trial (POINT) evaluated the use of dual antiplatelet therapy versus single antiplatelet agent in patients with small ischemic stroke or TIAs due to intracranial atherosclerotic disease in China. Dual antiplatelet therapy is associated with a reduction in stroke recurrence from 11.7% to 8.2%. Although some advocate for anticoagulation in crescendo TIA, there is limited evidence of efficacy, but there are data that heparinization is safe.

References:

  1. Johnston DCC, Hill MD. The patient with transient cerebral ischemia: a golden opportunity for stroke prevention. CMAJ. 2004;107:1134-1137.
  2. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.
  3. Wang Y, Wang Y, Zhao X. Clopidogrel with aspiring in acute minor stroke or ischemic attack. N Engl J Med. 2013;369:11-19.