What is the management approach for focal cerebral arteriopathy without ischemic stroke?

Management of Focal Cerebral Arteriopathy Without Ischemic Stroke

In patients with focal cerebral arteriopathy who have not experienced ischemic stroke, initiate aspirin 75-325 mg daily for cardiovascular protection and implement aggressive atherosclerotic risk factor modification, while avoiding revascularization procedures. 1

Medical Management

Antiplatelet Therapy

• Aspirin 75-325 mg daily is the cornerstone of treatment for patients with cerebrovascular arteriopathy, even in the absence of stroke symptoms 1
• This recommendation is based on Class I, Level B evidence for prevention of myocardial infarction and other ischemic cardiovascular events 1
• For patients with aspirin allergy or contraindications, clopidogrel 75 mg daily is a reasonable alternative 1

Important caveat: While antiplatelet therapy prevents systemic cardiovascular events, the benefit for stroke prevention specifically in asymptomatic patients has not been definitively established 1

Atherosclerotic Risk Factor Modification

Medical therapy and lifestyle modification should follow the same aggressive standards used for symptomatic extracranial carotid atherosclerosis 1:

• Blood pressure control: Antihypertensive therapy reduces stroke risk, with the degree of blood pressure reduction being more important than the specific agent used 1
• Lipid management: High-dose statin therapy (atorvastatin 80 mg daily demonstrated in SPARCL trial) reduces stroke risk by 16% and ischemic stroke by 22% 1
• Smoking cessation: Smoking increases ischemic stroke risk by 25-50%, and cessation substantially reduces this risk 1
• Diabetes management: Optimize glycemic control, though intensive glucose lowering alone has not shown stroke reduction benefit 1

Surveillance Strategy

Serial Imaging

• Annual noninvasive imaging (MRA or CTA preferred over ultrasound) is reasonable initially to assess disease progression and detect new lesions 1
• Studies may be repeated less frequently once arterial stability has been confirmed 1
• For vertebral artery involvement, MRA or CTA is specifically recommended over ultrasound imaging 1

Revascularization: Not Indicated

Revascularization procedures (surgical or endovascular) should NOT be performed in asymptomatic patients with focal cerebral arteriopathy 1:

• This is a Class III (No Benefit) recommendation for asymptomatic patients with asymmetrical blood pressure, bruits, or flow abnormalities 1
• The only exception is when the internal mammary artery is required for myocardial revascularization 1

Special Considerations

Distinguishing Focal Cerebral Arteriopathy from Progressive Conditions

• Follow-up intracranial imaging is essential to differentiate focal cerebral arteriopathy from progressive arteriopathies like moyamoya disease 2
• Focal cerebral arteriopathy is characterized by nonprogressive unifocal and unilateral stenosis, typically showing resolution or improvement on interval imaging 2
• If arterial progression is documented, reconsider the diagnosis and management approach 3, 2

Anticoagulation: Generally Not Recommended

• Antiplatelet agents are preferred over oral anticoagulation for patients with cerebrovascular atherosclerosis without ischemic symptoms (Class I, Level C) 1
• Anticoagulation should only be considered if there is a separate indication such as atrial fibrillation or mechanical heart valve 1

Key clinical pitfall: Do not confuse focal cerebral arteriopathy with conditions requiring different management strategies such as moyamoya disease (which may require surgical revascularization) or arterial dissection (which may require anticoagulation) 3, 4. The nonprogressive nature of focal cerebral arteriopathy on follow-up imaging is the distinguishing feature 2.