Chapter 89 - Cerebrovascular disease medical therapy

Question 1

Best medical therapy on stroke and CV events

Answer 1

1) Antiplatelet (1 or 2) - reduce stroke and MACE 2) Anti-HTN to reduce 10/5 mmHg or to 140/90 (130/90 if lacunarin HTN pt) - reduce stroke 3) DM: A1c <7 - reduce stroke 4) smk cessation - reduce stroke and MACE 5) statin reduce LDL by 50% or < 70 mg/dl 6) alcohol - avoid excessive use

Question 2

HTN control around stroke

Answer 2

within first 24 hr should not aggressively lower BP but after 24 yes

Question 3

ACCORD trial on diabetes control for stroke

Answer 3

251 patient randomized to tight vs routine control No benefit of tight control ( a1c <6) in fact higher mortality in tighet control recommend A1C < 7 is sufficient

Question 4

ADVANCE trial

Answer 4

randomized 11140 patient for targets of < 6.5 and < 7 A1c no difference

Question 5

Stroke prevention by aggressive reduction in cholesterol level trial (SPARCL)

Answer 5

1) atorvastatin 80 mg on reducing subsequent stroke in pt with CVA without CAD and moderate LDL (100-190) 2) 5 year reduced stroke and CV risk in statin group 3) increase risk of hemorrhagic stroke in statin group 4) biggest pt in people with biggest LDL reduction

Question 6

Alcohol on stroke

Answer 6

Mild consuption < 2 drinks/day associated wtih reduced risk of stroke

Question 7

Define metabolic syndrome

Answer 7

1) increased waist circumference (>102 cm male; > 88cm female) 2) TG > 150 mg/dl 3) HDL < 50 male or 40 female 4) BP > 135/85 5) fasting glucose > 100 mg/dl 3/5 = diagnostic

Question 8

European stroke prevention study ESPS-1

Answer 8

325 ASA + 75 dipyridamole better than placebo at stroke prevention

Question 9

ESPS-2

Answer 9

ASA and dipyridamole reduced stroke combination therapy even better but SE = headache, GI symptoms same observation in PROFESS study: combination not better than plavix alone

Question 10

Ticlopidine in stroke prevention

Answer 10

250 mg po BID lower bleeding risk than ASA side effect: neutropenia, TTP

Question 11

Clopidogrel vs aspirin in patients at risk of ischemic events (CAPRIE) trial

Answer 11

1) 19000 patients 2) plavix 5.32 vs asa 5.83 CV event rate minimal but significant improvement

Question 12

MATCH trial

Answer 12

1) recent stroke patients or TIA 2) plavix vs DAPT 3) no benefit of adding ASA but increase bleeding 1.3% absolute risk

Question 13

CHARISMA trial

Answer 13

1) ASA vs DAPT 2) no difference in effect

Question 14

DAPT in stroke

Answer 14

1) reduce stroke rate HR 0.61 2) increase bleeding HR 1.71 after CEA

Question 15

Biggest predictor of future stroke

Answer 15

Stroke/tia within 6 months after 6 months plaque has stabilized

Question 16

Key carotid trials and lesions that show significant benefit from NASCET ECST ACAS ACST CEA vs BMT with rate of stroke

Answer 16

TABLE 89.2

Question 17

ACSRS on controlateral stroke history in now asymptomatic ipsilater risk

Answer 17

still higher than total asymptomatic assumes that plaque morphology on both sides are similar

Question 18

Contralateral carotid occlusion with ipsilateral stenosis

Answer 18

1) ACAS showed decrease stroke at 5 years (weird) 2) ACST and AbuRahma showed increased risk of stroke with contralateral occlusion likely has to do with with amount of collateral intracranial circulation

Question 19

Clinical silent emboli detection

Answer 19

1) evidence on CT or MRI 2) embolic material in ipsilatera MCA using TCD

Question 20

Asymptomatic patients that have had a silent cortical infarction on CT

Answer 20

20%

Question 21

Asymptomatic patients degree of stenosis relationship to stroke risk

Answer 21

ACAS and ACST did not identify this 1) underpowered 2) duplex rather than angiographic determination of stenosis 3) uneven distribution of degree of stenosis 4) not enough strokes (hits) natural history study suggest a correlation NASCET contralateral disease suggest a relationship

Question 22

Plaque characteristics associated with increased stroke risk

Answer 22

1) diameter stenosis 2) ulceration 3) plaque progression 4) echolucent plaque 5) plaque area 6) disrupted fibrous cap 7) discrete white areas within plaque 8) active inflammation on MRI

Question 23

Patient factors associated with increased stroke risk

Answer 23

1) ipsilateral CVA 2) history of contralateral stroke 3) contralateral carotid occlusion 4) renal insufficiency 5) smoking 6) clinically silent emboli on TCD or MRI/CT

Question 24

Life expectancy on decision to treat symptomatic and asymptomatic

Answer 24

Symptomatic benefits quite evident therefore treat always Asymptomatic needs survival at least 3-5 years

Question 25

Higher risk of stroke in carotid stenting after this age

Answer 25

64

Question 26

NASCET stroke risk perioperative in patients with and without contralateral carotid occlusion

Answer 26

14% vs 5.8% metaanalysis shows slight increase in risk not as drastic

Question 27

Factors associated with stroke risk for CEA vs that for CAS

Answer 27

CEA 1) CAD/CHF 2) lesion above C2 or below clavicle 3) scarring 4) recurrent stenosis 5) neck stoma CAS 1) symptomatic lesion (especially in first week) 2) age > 70 3) vessel/arch tortuosity 4) adverse lesion characteristics

Question 28

Adverlesion characteristics bad for CAS

Answer 28

1) length > 15 mm 2) echolucent, irregular 3) tandem lesions 4) pre-occlusive lesions 5) circumferential calcification

Question 29

SPARCL trial

Answer 29

demonstrate improved risk reduction with improved medical therapy for stroke does not differentiate stroke caused by carotid vs all stroke carotid is only 20%

Question 30

Abbott meta analysis on asymptomatic carotid stenosis 50%

Answer 30

1) 11 trials 2) 3724 patients 3) 1985-2007 4) risk of stroke declined in medical group now similar to surgical cohort in ACAS FLAW 1) heterogenous including complete asymptomatic ACAS and contralateral asymptomatic from NASCET and ECST 2) included stnosis from 50-100% (including total occlusion) 3) ACST was excluded for no apparent reason

Question 31

SMART study

Answer 31

1) 2684 neurologically asymptomatic with arterial disease or diabetes 2) 8% had carotid disease > 50% 3) stroke risk trended towards higher risk with higher lesion

Question 32

REACH registry

Answer 32

2x increase stroke in asymptomatic > 70% most pt were on statins

Question 33

SAMMPRIS trial

Answer 33

1) BMT vs intracranial angioplasty for patients with symptomatic intracranial carotid stenosis 2) BMT alone just as good and negated benefit of endo intervention

Question 34

CREST

Answer 34

1) 2500 normal risk patient (1182 asymptomatic) to CAS or CEA 2) DAPT and protection devices for CAS 3) no difference in composite MACE 4) stroke less in CEA, MI less in CAS 5) age > 64 worse for CAS 6) stroke and death benefit favor CEA in symptomatic disease

Question 35

CREST 10 year

Answer 35

1) late stroke and death favor CEA driven by perioperative events 2) restenosis the same

Question 36

ACT1 trial

Answer 36

1) 1453 patients - stopped early because of slow enrollment 2) no difference between CAS and CEA for MACE or perioperative stroke/death 3) freedom from ipsilateral stroke > 97% at 3 years and 94% at 5 years

Question 37

Societal guidelines on treating carotid disease

Answer 37

TABLE 89.6

Question 38

Treatment for symptomatic < 50% stenosis

Answer 38

BMT

Question 39

Treatment for asymptomatic < 50% stenosis

Answer 39

if no other manifestation of CV disease then not even BMT

Question 40

Treatment of asymptomatic with carotid stenosis 70-99%

Answer 40

operate if life expectancy 3-5 years CAS not done over age 70

Question 41

Role of urgent or expedited Carotid intervention

Answer 41

unstable neurologic syndromes 1) Crescendo TIA 2) stroke in evolution (waxing and waning neurologic events)

Question 42

Rate of restenosis after CEA and CAS

Answer 42

8-12%

Question 43

Significance on the timing of restenosis

Answer 43

< 24 months likely intimal hyperplasia = relatively benign > 36 months may be new atherosclerotic disease = might need intervention

Question 44

Radiation induced stenosis treated with CEA or CAS

Answer 44

1) stroke risk same 3.5-3.9% 2) CEA higher CN injury 3) CAS higher restenosis