Ask the Experts - What Is the Next Strategy for a Patient With...
Ask the Experts - What Is the Next Strategy for a Patient With...
A 58-year-old male patient of mine has been experiencing frequent transient ischemic attacks (TIAs) (habitual signs and symptoms: dysarthria and left hemiparesis) for about 1 year. The events last 10-20 minutes and occur 2-3 times a week. He has no hypertension or diabetes, but a history of minor stroke. He smokes 1+ packs per day.
The brain MRA showed moderate stenosis of the intracranial internal carotid arteries (ICAs) bilaterally, but more severe on left. The neck duplex showed mild to moderate atherosclerotic changes. At present, we are using aspirin 100 mg/day + ticlopidine 300 mg/day + Coumadin 7.5 mg/day (INR 2.5-3), but the TIAs persist. What is the next strategy to help my patient?
I think that the present regimen is too aggressive with reference to bleeding risk in this patient. Furthermore, observational studies suggest that warfarin may be more effective than aspirin in patients with intracranial stenosis. There are no controlled trials of warfarin alone in this situation and no clinical trials at all combining it with antiplatelet therapy. With warfarin or warfarin-plus-aspirin regimens in the setting of intracranial vessel stenosis, however, the bleeding risk probably remains acceptable in a patient younger than 60 years of age.
It is likely that the events are not truly embolic but may represent low perfusion pressure in a patient with intracranial atheroma. I would probably begin using warfarin, keeping the patient flat for a couple of days, checking the blood pressure and thus avoiding hypotensions. This strategy has been successful in a patient presently under my care who has repeated events due to basilar stenosis; she can now be mobilized, after 3-4 days of that regimen.
Perhaps MRI would in fact demonstrate that there is a small infarct, which could be responsible for the fluctuating or pseudo-TIAs phenomena. If everything else fails I would try an antiepileptic agent, for instance carbamazepine or valproate, even if the EEG is unremarkable (which it usually is in confirmed cases of vascular focal epilepsy).
A 58-year-old male patient of mine has been experiencing frequent transient ischemic attacks (TIAs) (habitual signs and symptoms: dysarthria and left hemiparesis) for about 1 year. The events last 10-20 minutes and occur 2-3 times a week. He has no hypertension or diabetes, but a history of minor stroke. He smokes 1+ packs per day.
The brain MRA showed moderate stenosis of the intracranial internal carotid arteries (ICAs) bilaterally, but more severe on left. The neck duplex showed mild to moderate atherosclerotic changes. At present, we are using aspirin 100 mg/day + ticlopidine 300 mg/day + Coumadin 7.5 mg/day (INR 2.5-3), but the TIAs persist. What is the next strategy to help my patient?
I think that the present regimen is too aggressive with reference to bleeding risk in this patient. Furthermore, observational studies suggest that warfarin may be more effective than aspirin in patients with intracranial stenosis. There are no controlled trials of warfarin alone in this situation and no clinical trials at all combining it with antiplatelet therapy. With warfarin or warfarin-plus-aspirin regimens in the setting of intracranial vessel stenosis, however, the bleeding risk probably remains acceptable in a patient younger than 60 years of age.
It is likely that the events are not truly embolic but may represent low perfusion pressure in a patient with intracranial atheroma. I would probably begin using warfarin, keeping the patient flat for a couple of days, checking the blood pressure and thus avoiding hypotensions. This strategy has been successful in a patient presently under my care who has repeated events due to basilar stenosis; she can now be mobilized, after 3-4 days of that regimen.
Perhaps MRI would in fact demonstrate that there is a small infarct, which could be responsible for the fluctuating or pseudo-TIAs phenomena. If everything else fails I would try an antiepileptic agent, for instance carbamazepine or valproate, even if the EEG is unremarkable (which it usually is in confirmed cases of vascular focal epilepsy).
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