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| {{SI}} | | {{Vertebrobasilar insufficiency}} |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{SK}} VBI | | {{SK}} Basilar artery insufficiency; Basilar artery ischemia; Basilar artery stenosis; Vertebral artery insufficiency; Vertebral artery ischemia; Vertebral artery stenosis; Vertebrobasilar dolichoectasia; Vertebrobasilar ischemia |
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| == Overview == | | ==[[Vertebrobasilar insufficiency overview|Overview]]== |
| '''Vertebrobasilar insufficiency''' (VBI), or vertebral basilar ischemia, refers to a temporary set of symptoms due to decreased blood flow in the posterior circulation of the brain. The posterior circulation supplies blood to the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex (responsible for vision). Therefore, the symptoms due to VBI vary according to which portions of the brain experience significantly decreased blood flow. In the United States, 25% of strokes (see [[stroke]]) and transient ischemic attacks (see [[transient ischemic attack]]) occur in the vertebrobasilar distribution. These must be separated from strokes arising from the anterior circulation, which involves the carotid arteries.
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| ==Historical Perspective== | | ==[[Vertebrobasilar insufficiency historical perspective|Historical Perspective]]== |
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| ==Classification== | | ==[[Vertebrobasilar insufficiency classification|Classification]]== |
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| ==Pathophysiology== | | ==[[Vertebrobasilar insufficiency pathophysiology|Pathophysiology]]== |
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| ==Causes== | | ==[[Vertebrobasilar insufficiency causes|Causes]]== |
| ===Life Threatening Causes===
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| ===Common Causes=== | | ==[[Vertebrobasilar insufficiency differential diagnosis|Differentiating Vertebrobasilar insufficiency from other Diseases]]== |
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| ===Causes by Organ System=== | | ==[[Vertebrobasilar insufficiency epidemiology and demographics|Epidemiology and Demographics]]== |
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| {|style="width:80%; height:100px" border="1"
| | ==[[Vertebrobasilar insufficiency risk factors|Risk Factors]]== |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[ Intracranial atherosclerosis ]], [[ vertebral artery dissections ]],
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| [[physiatric cervical manipulation ]]
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| [[Cervical spondylosis ]],[[degenerative cervical spine changes ]],[[cervical compressive lesions ]]
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Oncologic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Pulmonary'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Dental'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[ Postural changes,like head rotation or extension ]]
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| |}
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| ===Causes in Alphabetical Order=== | | ==[[Vertebrobasilar insufficiency natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Differentiating Vertebral Artery Disease from other Diseases==
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| ==Epidemiology and Demographics==
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| The incidence of VBI increases with age and typically occurs in the seventh or eighth decade of life. Reflecting [[atherosclerosis]], which is the most common cause of VBI, it affects men twice as often as women and is more prevalent in African Americans. Patients with [[hypertension]], [[diabetes]], smoking, and dyslipidemias also have a higher risk of developing VBI.
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| ==Risk Factors==
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| ==Screening==
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| ==Natural History, Complications and Prognosis==
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| ===Complications===
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| One of the complications is [[vertebral artery dissection]]. It is the development of [[Dissection (medical)|dissection]] (a flap-like tear) in the [[vertebral artery]]. It is commonly associated with [[physical trauma]] but may also develop spontaneously. It is a major cause of [[stroke]] in young people.
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| ==Diagnosis== | | ==Diagnosis== |
| The evaluation for VBI starts with a history and physical exam, with great emphasis on the cardiovascular and neurologic exam. It also includes a work-up to exclude benign conditions (such as [[labyrinthitis]], [[vestibular neuronitis]], and [[benign paroxysmal positional vertigo]]) that have overlapping signs and symptoms. However, the exact work-up largely depends on the patient’s age and known risk factors. For middle-aged patients, a cardiovascular risk factor evaluation is important. This often includes a cholesterol level, lipid profile (see this [http://www.americanheart.org/presenter.jhtml?identifier=183] to determine what your cholesterol level means), ECG, and echocardiogram. If a person with VBI is under age 45 and has no evidence for atherosclerosis, a work-up for hypercoagulable states (Lupus anticoagulant, [[anti-cardiolipin antibodies]], protein C, protein S, antithrombin III deficiencies) is indicated.
| | [[Vertebrobasilar insufficiency history and symptoms|History and Symptoms]] | [[Vertebrobasilar insufficiency physical examination|Physical Examination]] | [[Vertebrobasilar insufficiency laboratory findings|Laboratory Findings]] | [[Vertebrobasilar insufficiency CT|CT]] | [[Vertebrobasilar insufficiency MRI|MRI]] | [[Vertebrobasilar insufficiency other imaging findings|Other Imaging Findings]] | [[Vertebrobasilar insufficiency other diagnostic studies|Other Diagnostic Studies]] |
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| Imaging studies are rarely required to diagnose VBI, but sometimes computed tomography (CT) is performed first. The CT is extremely sensitive in detecting hemorrhage. However, magnetic resonance imaging (MRI) is superior to the CT in detecting ischemic changes in the vertebrobasilar distribution. Magnetic resonance angiography (MRA) also can be used to identify vertebrobasilar occlusions, but it can often overestimate the degree of occlusion.
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| ===History===
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| ===Symptoms===
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| [[Vertigo (medical)|Vertigo]] (commonly described as the environment spinning or as if the person is twirling in space) is the most recognizable and quite often the sole symptom of decreased blood flow in the vertebrobasilar distribution. The vertigo due to VBI rarely is brought on by head turning, which could occlude the ipsilateral vertebral artery and result in decreased blood flow to the brain if the contralateral artery is occluded. When the vertigo is accompanied by double vision ([[diplopia]]), graying of vision, and blurred vision, patients often go to the [[ophthalmologist]]. If the VBI progresses, there may be weakness of the quadriceps and, to the patient, this is felt as a buckling of the knees. The patient may suddenly become weak at the knee and crumple (often referred to as a “drop attack”). Such a fall can lead to significant head and orthopedic injury, especially in the elderly.
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| Transient ischemic attacks due to VBI will, by definition, have symptoms resolved within 24 hours. More often, however, the symptoms are very brief, lasting a few seconds to half an hour. These symptoms are often provoked by sudden and temporary drops in blood pressure. Postural changes (see [[orthostatic hypotension]]), such as getting out of bed too quickly or standing up after sitting for extended periods of time, often provoke these attacks. Exercise of the legs may also bring on the symptoms of VBI. For the sedentary older subject, going up a flight of stairs or walking the dog may be enough to cause pooling of blood in the legs and a drop in blood pressure in the distal arteries of the head. Heat and [[dehydration]] may also be contributing causes.
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| ===Physical Examination===
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| ===Laboratory Finding===
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| ====CT====
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| zxcvvbnnmn.<ref name="pmid18616088">Otto V, Fischer B, Schwarz M, Baumann W, Preibisch-Effenberger R (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18616088 Treatment of vertebrobasilar insufficiency--associated vertigo with a fixed combination of cinnarizine and dimenhydrinate.] ''Int Tinnitus J'' 14 (1):57-67. PMID: [http://pubmed.gov/18616088 18616088]</ref>
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| ====MRI====
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| ==Treatment== | | ==Treatment== |
| Patients should discuss with their physician possible causes for their VBI symptoms. As discussed above, postural changes, exercise, and dehydration are some of the likely culprits. Treatment usually involves lifestyle modifications. For example, if VBI is attributed mainly to postural changes, patients are advised to slowly rise to standing position after sitting for a long period of time. An appropriate exercise regimen for each patient can also be designed in order to avoid the excessive pooling of blood in the legs. Dehydrated patients are often advised to increase their water intake, especially in hot, dry climates. Finally, when applicable, patients are often advised to stop smoking and to control their hypertension, diabetes, and cholesterol level.
| | [[Vertebrobasilar insufficiency medical therapy|Medical Therapy]] | [[Vertebrobasilar insufficiency surgery|Surgery]] | [[Vertebrobasilar insufficiency primary prevention|Primary Prevention]] | [[Vertebrobasilar insufficiency secondary prevention|Secondary Prevention]] | [[Vertebrobasilar insufficiency cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Vertebrobasilar insufficiency future or investigational therapies|Future or Investigational Therapies]] |
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| In the event that a patient suffers a “drop attack,” and especially for the elderly population, the most important action is to be evaluated for associated head or other injuries. To prevent drop attacks, patients are advised to “go to the ground” before the knees buckle and shortly after feeling dizzy or experiencing changes in vision. Patients should not be concerned about the social consequences of suddenly sitting on the floor, whether in the mall or sidewalk, as such actions are important in preventing serious injuries.
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| Sometimes, to prevent further occlusion of blood vessels, patients are started on an antiplatelet agent (aspirin, clopidogrel, or aspirin/dipyridamole) or sometimes an anticoagulant (warfarin) once hemorrhage has been excluded with imaging.
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| For treatment of vertebrobasilar stenosis due to atherosclerosis, researchers from Stanford University found that intracranial angioplasty can be performed with an annual stroke rate in the territory of treatment of 3.2% and 4.4% for all strokes, including periprocedural events. Randomized control trials need to be performed.
| | ==Case Studies== |
| | [[Vertebrobasilar insufficiency case study one|Case #1]] |
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| ===Pharmacotherapy===
| | {{WikiDoc Help Menu}} |
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| ===Surgery and Device Based Therapy===
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| ====Indications for Surgery====
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| ==2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 |doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505 }}</ref>==
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| ===Vascular Imaging in Patients with Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 |pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505 }} </ref>===
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Noninvasive imaging by [[CTA]] or [[MRA]] for detection of vertebral artery disease should be part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation and those with [[subclavian steal syndrome]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with asymptomatic bilateral carotid occlusions or unilateral [[carotid artery]] occlusion and incomplete [[circle of Willis]] should undergo noninvasive imaging for detection of vertebral artery obstructive disease. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients whose symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended rather than ultrasound imaging for evaluation of the vertebral arteries. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with symptoms of posterior cerebral or cerebellar ischemia, serial noninvasive imaging of the extracranial vertebral arteries is reasonable to assess the progression of atherosclerotic disease and exclude the development of new lesions. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with posterior cerebral or cerebellar ischemic symptoms who may be candidates for [[revascularization]], catheter-based contrast angiography can be useful to define vertebral artery pathoanatomy when noninvasive imaging fails to define the location or severity of stenosis. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients who have undergone vertebral artery revascularization, serial noninvasive imaging of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| ===Management of Atherosclerotic Risk Factors in Patients with Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124| issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505 }} </ref>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Medical therapy and lifestyle modification to reduce atherosclerotic risk are recommended in patients with vertebral atherosclerosis according to the standards recommended for those with extracranial carotid atherosclerosis<ref name="pmid12485966">{{cite journal |author= |title=Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report|journal=Circulation |volume=106 |issue=25 |pages=3143–421 |year=2002 |month=December |pmid=12485966 |doi= |url=}}</ref><ref name="pmid9514413">{{cite journal |author=Ginsberg HN, Kris-Etherton P, Dennis B, ''et al.'' |title=Effects of reducing dietary saturated fatty acids on plasma lipids and lipoproteins in healthy subjects: the DELTA Study, protocol 1|journal=Arterioscler. Thromb. Vasc. Biol. |volume=18 |issue=3 |pages=441–9 |year=1998 |month=March |pmid=9514413 |doi= |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In the absence of contraindications, patients with [[atherosclerosis]] involving the vertebral arteries should receive[[antiplatelet therapy]] with [[aspirin]] (75 to 325 mg daily) to prevent [[MI]] and other ischemic events<ref name="pmid11786451">{{cite journal |author= |title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients |journal=BMJ |volume=324 |issue=7329|pages=71–86 |year=2002 |month=January |pmid=11786451 |pmc=64503 |doi= |url=}}</ref><ref name="pmid8298418">{{cite journal |author= |title=Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration |journal=BMJ |volume=308 |issue=6921 |pages=81–106 |year=1994 |month=January |pmid=8298418 |pmc=2539220 |doi= |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Antiplatelet drug therapy is recommended as part of the initial management for patients who sustain ischemic stroke or TIA associated with extracranial vertebral atherosclerosis. Aspirin (81 to 325 mg daily), the combination of [[aspirin]] plus extended-release [[dipyridamole]] (25 and 200 mg twice daily, respectively), and [[clopidogrel]] (75 mg daily) are acceptable options. Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies<ref name="pmid18322260">{{cite journal |author=Adams RJ, Albers G, Alberts MJ, ''et al.'' |title=Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack |journal=Stroke |volume=39|issue=5 |pages=1647–52 |year=2008 |month=May |pmid=18322260 |doi=10.1161/STROKEAHA.107.189063 |url=}}</ref><ref name="pmid11786451">{{cite journal |author= |title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients |journal=BMJ |volume=324 |issue=7329|pages=71–86 |year=2002 |month=January |pmid=11786451 |pmc=64503 |doi= |url=}}</ref><ref name="pmid8918275">{{cite journal |author= |title=A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee |journal=Lancet |volume=348 |issue=9038 |pages=1329–39 |year=1996|month=November |pmid=8918275 |doi= |url=}}</ref><ref name="pmid15276392">{{cite journal |author=Diener HC, Bogousslavsky J, Brass LM, ''et al.'' |title=Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial|journal=Lancet |volume=364 |issue=9431 |pages=331–7 |year=2004 |pmid=15276392 |doi=10.1016/S0140-6736(04)16721-4 |url=}}</ref><ref name="pmid8981292">{{cite journal |author=Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A |title=European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke|journal=J. Neurol. Sci. |volume=143 |issue=1-2 |pages=1–13 |year=1996 |month=November |pmid=8981292 |doi= |url=}}</ref><ref name="pmid18753638">{{cite journal |author=Sacco RL, Diener HC, Yusuf S, ''et al.'' |title=Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke |journal=N. Engl. J. Med. |volume=359 |issue=12|pages=1238–51 |year=2008 |month=September |pmid=18753638 |pmc=2714259 |doi=10.1056/NEJMoa0805002 |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with atherosclerosis of the extracranial vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including those with allergy to aspirin, either clopidogrel (75 mg daily) or [[ticlopidine]] (250 mg twice daily) is a reasonable alternative. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| ==References==
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| {{Reflist|2}}
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| {{WH}} | |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Cardiovascular diseases]] | | [[Category:Cardiovascular diseases]] |
| | [[Category:Disease]] |
| [[Category:Neurological disorders]] | | [[Category:Neurological disorders]] |
| [[Category:Neurology]] | | [[Category:Neurology]] |
| [[Category:Mature chapter]]
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| [[Category:Disease]]
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