Ask the Experts - Medical Therapy of Pontine Stroke
Ask the Experts - Medical Therapy of Pontine Stroke
I have a patient with a pontine stroke. He was taking 325 mg of aspirin at the time of the event. MRA shows a stenotic but not occluded vertebrobasilar system. What's my next best choice with respect to medical therapy: more aspirin, clopidogrel, ticlopidine, or Coumadin? The patient is in his 60s and has multiple stroke risk factors, including hypertension, diabetes, and hypercholesterolemia.
This is a very interesting and multifaceted question, with several possible answers. First, from the perspective of evidence-based medicine, clopidogrel has been found to be more effective than aspirin in preventing atherothrombotic manifestations after a first event, especially in a high-risk population with multiple risk factors. Less evidence exists to support switching from aspirin to clopidogrel after a new event (so-called aspirin failure), but I certainly would consider doing so. Thus, there are several reasons for moving toward giving the patient 75 mg of clopidogrel once daily.
A second approach would be anticoagulation. Over a number of years, many neurologists have treated patients who have intracranial vessel stenosis with Coumadin to achieve an INR of 2-3. Some physicians have even added low-dose aspirin to that; however, no good prospective data are available to support this approach. Nevertheless, I have successfully treated several patients who have basilar artery stenosis with Coumadin.
Finally, stenting of symptomatic intracranial vessel stenoses is an option. This is still an experimental but feasible procedure. The real procedural risk is unknown; however, we know that the risk of a symptomatic basilar artery stenosis is high. We have some good experience with basilar artery stenting in high-risk patients. Several centers in the United States are testing this procedure, including University of California San Francisco, Cleveland Clinic, University of Washington, Seattle, and certainly many more.
I have a patient with a pontine stroke. He was taking 325 mg of aspirin at the time of the event. MRA shows a stenotic but not occluded vertebrobasilar system. What's my next best choice with respect to medical therapy: more aspirin, clopidogrel, ticlopidine, or Coumadin? The patient is in his 60s and has multiple stroke risk factors, including hypertension, diabetes, and hypercholesterolemia.
This is a very interesting and multifaceted question, with several possible answers. First, from the perspective of evidence-based medicine, clopidogrel has been found to be more effective than aspirin in preventing atherothrombotic manifestations after a first event, especially in a high-risk population with multiple risk factors. Less evidence exists to support switching from aspirin to clopidogrel after a new event (so-called aspirin failure), but I certainly would consider doing so. Thus, there are several reasons for moving toward giving the patient 75 mg of clopidogrel once daily.
A second approach would be anticoagulation. Over a number of years, many neurologists have treated patients who have intracranial vessel stenosis with Coumadin to achieve an INR of 2-3. Some physicians have even added low-dose aspirin to that; however, no good prospective data are available to support this approach. Nevertheless, I have successfully treated several patients who have basilar artery stenosis with Coumadin.
Finally, stenting of symptomatic intracranial vessel stenoses is an option. This is still an experimental but feasible procedure. The real procedural risk is unknown; however, we know that the risk of a symptomatic basilar artery stenosis is high. We have some good experience with basilar artery stenting in high-risk patients. Several centers in the United States are testing this procedure, including University of California San Francisco, Cleveland Clinic, University of Washington, Seattle, and certainly many more.
