Exceptions and Other Considerations
These evidence-based recommendations are directed toward a specific group of patients with high-grade stenosis (70%–99%), a single symptomatic vessel, and relatively short segments of stenosis (< 14 mm) based on the inclusion and exclusion criteria for the SAMMPRIS trial [7]. Additionally, these patients were not enrolled during the immediate period following an acute ischemic event. There is less evidence on the management of patients who present with < 70% symptomatic ICAD but we can infer that therapy with DAT, statins, and risk factor modification are still of benefit for patients with 50%–69% stenosis or those requiring treatment during the acute evaluation [13]. Additionally, some of these SAMMPRIS exclusion criteria were included to select patients who could be considered intracranial stenting candidates (eg, short segment stenosis, single vessel disease, etc) and are not considered to impact on the benefits of the aggressive medical management regimen.
Further Evaluation
The patient was initiated on antithrombotic therapy on hospital day 2 (24 hours after IV tPA administration) with aspirin 325 mg daily and clopidogrel 300 mg oral load followed by 75 mg daily, ranitidine 150 mg twice a day to reduce gastroesophageal reflux and atorvastatin 80 mg daily. On hospital day 3, his neurological exam remained stable and he was initiated on losartan 25 mg daily with a plan to titrate the dose up as an outpatient to achieve target blood pressure. The patient and his wife were advised to maintain a blood pressure log and provide it to his physicians at follow-up and was provided smoking cessation counseling with a plan to remain off tobacco after discharge utilizing nicotine patches. The patient was discharged from the hospital 4 days after admission with a diagnosis of acute ischemic stroke secondary to symptomatic ICAD from regional thromboembolism. Early outpatient follow-up was scheduled with his primary physician within 1 week after discharge to evaluate BP and a vascular neurologist within 1 month after discharge.
What factors predict recurrent stroke in patients with symptomatic ICAD?
As evidenced in the WASID post-hoc analysis, female sex, prior ischemic stroke (versus TIA), time from qualifying event to enrollment (≤ 17 days after ischemic event), severity of stenosis (≥ 70% stenosis) of the symptomatic vessel, and history of diabetes were identified as independent risk factors for recurrent stroke in this population [14].
How do we manage patients who continue to have symptoms despite optimal medical therapy?
When evaluating symptomatic ICAD patients with recur-rent neurologic symptoms, several important factors should be considered:
- Do the recurrent neurologic symptoms localize to the original ICAD location?
Patients with symptomatic ICAD often have multiple risk factors that put them at risk for other subtypes of ischemic stroke including lacunar stroke. Repeat neuro-imaging with brain MRI is recommended to confirm the localization of a recurrent stroke is inside or outside of the territory of the ICAD.
- Were the recurrent neurologic symptoms provoked?
Patients with ICAD can be uniquely sensitive to fluctuations in cerebral blood flow and oxygenation. Diabetic patients with ICAD can develop autonomic neuropathy that results in orthostatic hypotension. If patients have recurrent transient ischemic events associated with postural changes, adequate treatment of orthostasis can reduce recurrent ischemic events. Other provoked circumstances include patients who develop anemia and patients with untreated severe obstructive sleep apnea who may awake with recurrent ischemic events due to hypoxemia.