Antithrombotic Therapy for Cerebrovascular Disorders

Antithrombotic Therapy for Cerebrovascular DisordersDespite a declining incidence during the past 2 decades, stroke continues to be the most common and most feared neurologic disorder of the elderly. While primary cerebrovascular diseases of the large and small arteries supplying the brain cause the majority of strokes, cardiogenic brain embolism accounts for about 1 stroke in 6. Advances in diagnostic technology has allowed definition of the mechanism of brain ischemia in most patients. As our knowledge about antithrombotic and surgical therapies for stroke prevention and treatment has increased, it is clear that optimal management requires determination of stroke mechanism. A diagnosis of “cerebrovascular accident” (CVA), unspecified, is not adequate for choosing therapy. Importantly, clinical definition of mechanisms of ischemia has recently allowed design of trials to test preventive treatments in homogeneous populations with threatened stroke.
In 1984 we prepared a review of antithrombotic therapy for prevention and treatment of stroke. Many observational studies and large clinical trials have been reported in the interim, adding greatly to our knowledge about natural history and treatment. This review supplements and updates our previous reports, summarizing the role of antithrombotic therapy in cerebrovascular disease and particularly cardiogenic embolism. so

Differential Diagnosis of Stroke
The clinical hallmark of a stroke is the abrupt development of a focal neurologic deficit explainable by ischemia or bleeding in a particular vascular territory. About 2-3% of the time a nonvascular cause such as an intracranial neoplasm will be found mimicking a stroke. Intracerebral or subarachnoid hemorrhage accounts for 15% of strokes and is suspected by the history and physical examination and confirmed by CT scan and/or lumbar puncture. The vast majority of strokes, 85%, are ischemic arising from atherosclerotic large or small cerebral arterial disease. Clinical studies reviewed previously suggested that about 15% (range, 6-23%) of all ischemic strokes were cardioem-bolic.