Do patients with cerebral infarction need aspirin or statin treatment?

In tweets before nerve time, the CISS etiology typing of cerebral infarction was combed. Cerebral infarction is divided into five categories according to the cause: atherosclerotic, cardiac stroke, perforating artery disease, other causes, and unknown etiology.

Today we will comb through, what is the difference in treatment for different etiological typings? What issues do I need to be aware of?

1. Atherosclerotic

Atheroscleroticity of the aortic arch and atherosclerosis of the internal and external aortic arteries according to the site of onset can be divided into: atherosclerosis of the aortic arch and atherosclerosis of the internal and external intracranial aortics, and obstruction of perforating arteries (plaques or thrombosis) according to the underlying pathogenesis of the carrier arteries (plaques or thrombosis), arterial-arterial embolism, hypoperfusion/decreased embolism of embolus, and mixed mechanisms.

01. Anti-platelet aggregation therapy

According to the CHANCE study (Clopidogrel with aspirin in acute minor stroke or transient ischemic attack), for noncardiopathic mild strokes with an NIHSS score of ≤ 3, initiation of aspirin plus clopidogrel dual antiplatelet aggregation therapy within 24 hours of onset of illness is recommended for 21 days, reducing the risk of stroke recurrence within 90 days.

In addition, according to recent CHANCE-2 studies, we also need to consider pharmacogenomics differences and the like for individualized treatments.

02. Intensive lipid-lowering therapy

The results of the SPARCL (Stroke prevention by aggressive reduction in cholesterol levels) study showed that statin therapy significantly reduced the risk of recurrence of stroke, with enhanced lipid reduction (LDL decreasing ≤50% from baseline) benefiting more.

03. Surgical intervention

In patients with non-disabling stroke or TIA, treatment of stenosis can be performed relatively early if homotopy extracranial artery severe stenosis is combined. Carotid endarter decortication or carotid stent implantation is selected based on the patient's comorbid disease and vascular anatomical characteristics.

In patients with severe intracranial artery stenosis in the TIA supply area with ischemic stroke or TIA, angioplasty or stent implantation is not recommended as first-line therapy. Intensive pharmacotherapy to manage risk factors and short-term dual-antibody therapy may be considered.

04. Improve perfusion therapy

Because occlusive distal hypoperfusion is an important factor in stroke recurrence, treatment aimed at improving hypoperfusion can reduce recurrence and disability in patients, especially in patients with suspected hypoperfusion.

2. Cardiac stroke

Cardiac stroke is the most common and severe type of stroke other than atherosclerotic in larger arteries. For such patients, we need to further choose whether to initiate anticoagulation and the duration of anticoagulation depending on the etiology and infarction.

Antiplate therapy may be used in cases where large-scale infarction is not suitable for or is not suitable for anticoagulation. In addition to stroke-related treatments, primary cardiac disease should be actively treated.

01. Timing of initiation of anticoagulation therapy

1) For patients with transient ischemic attack, anticoagulation can be done after 1 day;

2) Patients with non-disabling small-area cerebral infarction, it is recommended to start anticoagulation therapy after 3 days;

3) Patients with moderate area infarction, anticoagulation can be started after 6 days;

4) For patients with a high risk of bleeding, large embolization area, or poor blood pressure control, the anticoagulation time should be extended to after 2 weeks.

The HAS-BLED score can help predict the risk of bleeding from anticoagulation, ≥ 3 points of 3 patients have a higher risk of bleeding.

02. Drug options for anticoagulation

Warfarin has clear therapeutic value in both primary and secondary prevention in patients with atrial fibrillation, and the optimal dose of treatment is to maintain an INR value of 2.0 to 3.0, which can take into account both efficacy and bleeding risk.

The anticoagulant effect of the new oral anticoagulant is not inferior to warfarin, and the complications of cerebral hemorrhage are less than warfarin, which has a good safety.

03. Etiological management

1) Atrial fibrillation:

In patients with aerobic fibrillation lasting >48 hours or of unknown duration, antithrombotic therapy should be performed with dose-adjusted warfarin (INR 2.0 to 3.0) or a novel oral anticoagulant for at least 3 weeks prior to proposed elective cardioversion.

Patients with hemodynamic instability (angina, myocardial infarction, or shock) should have cardiover immediately and anticoagulation initiated as soon as possible.

Patients with episodes of atrial fibrillation for less than 48 hours can have cardioversion directly with unfractionated heparin or low molecular weight heparin or novel oral anticoagulants, and can be non-anticoagulatory without embolic risk factors after cardioversion. However, in patients with stroke risk factors, long-term anticoagulation is indicated.

2) Mitral stenosis:

Warfarin or heparin anticoagulation is recommended in patients with rheumatic mitral stenosis without atrial fibrillation and in patients with a history of previous embolism or atrial (including ear) thrombosis. At the same time, anticoagulation should also be considered in patients with spontaneous development of the left atrium or significant enlargement of the left atrium with ultrasound. In the absence of a relevant history, antithrombotic therapy may be considered.

3) Prosthetic valve:

All patients after mechanical valve implantation should be given warfarin anticoagulation for life and regular monitoring, and new oral anticoagulants are not recommended for anticoagulation of mechanical valves.

For the first trimester after mitral and tricuspid biological valve implantation, warfarin anticoagulation is recommended, after which the risk of embolism is again assessed.

For the first 3 to 6 months after transcatheter aortic valve bioprogram implantation, aspirin plus clopidogrel antithrombotic therapy is recommended, and aspirin is maintained for a long time thereafter.

4) Mitral valve prolapse and reflux:

In patients with atrial fibrillation or atrial thrombosis, anticoagulation should be given.

3. Perforational artery disease

For the treatment of perforating artery disease, there is currently a lack of strong evidence-based medical evidence for treatment, and further clinical studies are still needed to confirm it.

1) For patients with ultravenous thrombolytic time window, double antiplatelet aggregation therapy for stroke protocols is still recommended according to the CHANCE study.

2) Platelet surface glycoprotein IIb/IIIa receptor antagonist tirofiban may improve symptom fluctuations and prognosis in patients with perforating artery disease, but its results need to be further confirmed by large-scale experiments.

3) At the same time, studies have shown that cilotazole may also prevent the activation of platelets and the further formation of white blood clots.

4. Other causes

01. Arterial dissection

Cervical artery dissection is a tear in the lining of the cervical artery that causes blood to flow into the wall of the tube to form an intramural hematoma, which in turn causes arterial stenosis, occlusion, or aneurysm-like changes, mainly the internal carotid artery dissection and vertebral artery dissection.

1) Antiplatelet or anticoagulant therapy can prevent the risk of stroke or death in patients with symptomatic arterial dissection.

2) If the patient has a large-scale cerebral infarction, a severe degree of neurological disability (NIHSS score > 15), and contraindications to the use of anticoagulation, the patient is inclined to use antiplatelet drugs;

3) If the dissection artery has severe stenosis, unstable thrombosis, intraluminal thrombosis or pseudoaneurysm, anticoagulation is preferred.

02. Moyamoya disease

Moyamoya disease is an etiology of unknown origin characterized by chronic progressive stenosis or occlusion at the end of the bilateral internal carotid artery and the anterior cerebral artery and the beginning of the middle cerebral artery, and is secondary to an abnormal vessel network at the base of the skull to form a cerebrovascular disease.

There are currently no effective drugs, and intracranial and extracranial vascular reconstruction may be a relatively effective treatment.

03. Vasculitis

Primary central nervous system vasculitis is an important cause of stroke, mainly manifested as headache, cognitive decline and seizures.

At present, there is no unified treatment plan, and the clinical treatment is mainly based on hormone therapy, and some patients can be combined with immunosuppressants.

Planning | Time capsule

This article was first published on Lilac Garden's professional platform: Nerve Time

Resources:

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