Secondary Stroke Prevention   

05 November 2004

Intracranial large vessel disease

·     symptomatic intracranial carotid, MCA or vertebro-basilar stenosis: anticoagulants vs antiplatelets not established; surgery not possible - use coumadin with INR in the range 2.0 - 3.0

·      symptomatic intracranial large vessel stenosis on coumadin with therapeutic INR (2.0 - 3.0): aim for INR 2.5 - 3.5 or add ASA to coumadin (INR 2.0 - 3.0)

Extracranial large vessel disease

·     symptomatic vertebral artery stenosis: anticoagulants vs antiplatelets not established; surgery not possible - use coumadin with INR in the range 2.0 - 3.0

·      symptomatic carotid artery stenosis: CEA is superior to medical mangement (established by radomized studies)

·       asymptomatic carotid artery stenosis (70% - 99%): CEA is superior to medical mangement (established by radomized studies)

·      asymptomatic carotid artery stenosis (50% - 69%): CEA is superior to medical mangement provided risk of surgery is low (established by radomized studies)

·      recently occluded carotid artery: anticoagulation with coumadin (INR 2.0 - 3.0) for 3 months

Aortic arch disease

·      symptomatic arotic arch atheroma: anticoagulants vs antiplatelets not established

Heart conditions

·      atrial fibrillation, prosthetic valve, recent myocardial infarction, left ventricular thrombus, atrial myxoma, non-ischemic cardiomyopathies with EF < 25%: anticoagulation with coumadin (INR 2.0 - 3.0)

·      paradoxical embolization in ASD, PFO, VSD, pulmonary AV fistula: anticoagulants vs antiplatelets vs surgery not established - may use coumadin (INR 2.0 - 3.0) for 2-3 months followed by antiplatelet