TIAs And Minor Infarction Management

The aim of treatment is to prevent subsequent cerebral infarction:

Establish diagnosis and exclude other pathologies causing transient neurological symptoms, e.g. migraine.

Establish which vessel is involved —■— carotid territory vertebrobasilar artery.

Correct predisposing condition.

Examine patient for evidence of extracranial vascular disease: Palpate carotids, upper limb pulses. Auscultate the neck for bruits. Check blood pressure in both arms. Examine heart.

Medical treatment

General Reduce risk factors as described (page 236).

Antiplatelet agents: several studies indicate that aspirin is a useful

/prophylactic in patients with TIAs. The UK TIA aspirin trial compared placebo with aspirin 1200 mg and aspirin 300 mg per day. Results showed no difference between the high and low dose, but both treatment groups showed an 18% reduction in end points (vascular and non-vascular events and mortality). Examination of individual end points - disabling stroke and vascular deaths, showed no significant benefit. Despite the possibility that Specific aspirin might predispose to haemorrhagic stroke, the authors recommend that

\a patient requiring prophylaxis for cerebrovascular or cardiovascular disease should receive aspirin (300 mg per day), provided no contraindications exist (e.g. peptic ulcer).

Ticlopidine, a new platelet antiaggregant has been compared with aspirin and appears slightly more effective, especially in women whose TIAs persist on aspirin.

Anticoagulation

In the absence of atrial fibrillation, there is no evidence that anticoagulated TIA patients do more favourably than control groups.

Surgical treatment

Carotid endarterectomy was introduced in 1954. Recent trials - European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have defined its role in treatment. High grade (>70%) stenosis should be operated on by an experienced surgeon. Mild stenosis (<30%) should be treated with antiplatelet drugs. The place of surgery in moderate stenosis (30%-70%) remains unclear. The role of angioplasty with or without 'stenting' is currently being assessed. Trials show surgery for asymptomatic carotid disease produces negligible benefit. Most surgery is confined to the carotid territory, though osteophytic vertebral artery compression, subclavian steal syndrome and vertebral artery origin stenosis are all amenable to surgery.

Superficial temporal to middle cerebral artery anastomosis (anterior circulation)

Extracranial-intracranial (EC-IC) bypass aims at enhancing the collateral circulation in patients with carotid or middle cerebral artery occlusion to lessen the likelihood of further ipsilateral infarction. A randomised multicentre international study, however, demonstrated that 'bypass was not superior to conservative treatment'. Despite many criticisms of the trial, this procedure has generally been abandoned. With the development of noninvasive techniques for assessing the intracranial collateral circulation, it is still possible that, with improved patient selection, this operation could gain favour in the future. 259

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