Updates on Prevention of Hemorrhagic and Lacunar Strokes

Abstract

Intracerebral hemorrhage (ICH) and lacunar infarction (LI) are the major acute clinical manifestations of cerebral small vessel diseases (cSVDs). Hypertensive small vessel disease, cerebral amyloid angiopathy, and hereditary causes, such as Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), constitute the three common cSVD categories. Diagnosing the underlying vascular pathology in these patients is important because the risk and types of recurrent strokes show significant differences. Recent advances in our understanding of the cSVD-related radiological markers have improved our ability to stratify ICH risk in individual patients, which helps guide antithrombotic decisions. There are general good-practice measures for stroke prevention in patients with cSVD, such as optimal blood pressure and glycemic control, while individualized measures tailored for particular patients are often needed. Antithrombotic combinations and anticoagulants should be avoided in cSVD treatment, as they increase the risk of potentially fatal ICH without necessarily lowering LI risk in these patients. Even when indicated for a concurrent pathology, such as nonvalvular atrial fibrillation, nonpharmacological approaches should be considered in the presence of cSVD. More data are emerging regarding the presentation, clinical course, and diagnostic markers of hereditary cSVD, allowing accurate diagnosis, and therefore, guiding management of symptomatic patients. When suspicion for asymptomatic hereditary cSVD exists, the pros and cons of prescribing genetic testing should be discussed in detail in the absence of any curative treatment. Recent data regarding diagnosis, risk stratification, and specific preventive approaches for both sporadic and hereditary cSVDs are discussed in this review article.

Anton’s syndrome: a rare and unusual form of blindness

“…This might be due to failure of posterior circulation vessels to eliminate beta amyloid peptide efficiently 13. There are also reported cases of bilateral occipital lobe haemorrhages due to PRES causing sudden onset blindness 14. Interesting feature of the first case presented here, is that the two haemorrhagic strokes are 4 years apart, favouring CAA.…”

Pharmacological management of modifiable cardiovascular risk factors (blood pressure and lipids) following diagnosis of myocardial infarction, stroke and diabetes: comparison between population-based studies in Russia and Norway

“…Here we did not have the capacity within the data to determine stroke sub-types. There is debate about the use of statins following haemorrhagic stroke [22,23], therefore different proportions of stroke sub-type within the studies could have impacted on subsequent medical management with lipid-lowering medication. However the consistent finding of differences across all three conditions suggests we have identified a fundamental difference in pharmacological management.…”

Updates on Prevention of Cardioembolic Strokes

“…Such patients include survivors of any type of ICH, people having imaging markers of higher ICH risk such as microbleeds, cortical superficial siderosis, moderate-to-severe white matter disease, older adults with dementia or high risk of falling, and patients with past history of bleeding in a different organ system. The neurologic conditions that increase ICH risk are further detailed in another article from this issue and a recent review [ 3 , 8 ].…”

“…Neurologists who are familiar with both ischemic and hemorrhagic stroke management need to balance the risks and benefits of different medical and nonpharmacological CE prevention approaches in conjunction with the cardiologists and other medical specialists. The most relevant markers of ICH risk are discussed in a separate paper on prevention of lacunar and hemorrhagic strokes published in this same issue of the Journal of Stroke [ 8 ]. The current article will review advances in CE stroke prevention emphasizing the aspects most relevant to the practicing neurologists and stroke specialists.…”