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2017 ; 23
(1, Cerebrovascular Disease
): 133-157
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Large Artery Atherosclerotic Occlusive Disease
#MMPMID28157748
Cole JW
Continuum (Minneap Minn)
2017[Feb]; 23
(1, Cerebrovascular Disease
): 133-157
PMID28157748
show ga
PURPOSE OF REVIEW: Extracranial or intracranial large artery atherosclerosis is
often identified as a potential etiologic cause for ischemic stroke and transient
ischemic attack. Given the high prevalence of large artery atherosclerosis in the
general population, determining whether an identified atherosclerotic lesion is
truly the cause of a patient's symptomatology can be difficult. In all cases,
optimally treating each patient to minimize future stroke risk is paramount.
Extracranial or intracranial large artery atherosclerosis can be broadly
compartmentalized into four distinct clinical scenarios based upon the individual
patient's history, examination, and anatomic imaging findings: asymptomatic and
symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and
extracranial vertebral artery atherosclerotic disease. This review provides a
framework for clinicians evaluating and treating such patients. RECENT FINDINGS:
Intensive medical therapy achieves low rates of stroke and death in asymptomatic
carotid stenosis. Evidence indicates that patients with severe symptomatic
carotid stenosis should undergo carotid revascularization sooner rather than
later and that the risk of stroke or death is lower using carotid endarterectomy
than with carotid stenting. Specific to stenting, the risk of stroke or death is
greatest among older patients and women. Continuous vascular risk factor
optimization via sustained behavioral modifications and intensive medical therapy
is the mainstay for stroke prevention in the setting of intracranial and
vertebral artery origin atherosclerosis. SUMMARY: Lifelong vascular risk factor
optimization via sustained behavioral modifications and intensive medical therapy
are the key elements to reduce future stroke risk in the setting of large artery
atherosclerosis. When considering a revascularization procedure for carotid
stenosis, patient demographics, comorbidities, and the periprocedural risks of
stroke and death should be carefully considered.
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