From the Guidelines
Management of degenerative vascular disease within the cerebral hemispheres should prioritize risk factor modification, including strict blood pressure control, lipid management, and lifestyle changes, as evidenced by the most recent guidelines 1. The goal of management is to reduce the risk of stroke and cognitive decline by addressing modifiable risk factors.
- Risk factor modification includes:
- Blood pressure control to targets below 130/80 mmHg using medications like ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics, as supported by studies such as the PROGRESS trial 1.
- Lipid management with statins, regardless of baseline cholesterol levels, typically atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily.
- Tight glycemic control for diabetic patients with a target HbA1c below 7%.
- Lifestyle modifications are crucial and include:
- Smoking cessation, as smoking increases the relative risk of ischemic stroke by 25% to 50% 1.
- Regular physical activity, such as 150 minutes weekly of moderate exercise.
- Adoption of a Mediterranean or DASH diet.
- Weight management and limiting alcohol consumption. According to the Canadian Stroke Best Practice Recommendations, 7th edition, individuals with vascular cognitive impairment should be assessed for medical and lifestyle vascular risk factors and managed to achieve maximum risk reduction for first-ever or recurrent stroke 1.
- Non-pharmacological management strategies include referrals to appropriate specialists to support and manage specific medical and lifestyle vascular risk factors and comorbidities.
- Additional support, such as communication tools, memory aids, caregiver and family participation, and support, may be required to optimize participation in goal-setting and/or engagement in interventions 1.
From the Research
Management of Degenerative Vascular Disease
The management of degenerative vascular disease within the cerebral hemispheres, specifically carotid stenosis, involves a combination of medical therapy, lifestyle modifications, and revascularization procedures.
- Medical Therapy: Optimal management requires the use of medications to control processes associated with atheroma and reduce the risk of embolic events 2. This includes antiplatelet therapy, such as aspirin, which should be considered in both asymptomatic and symptomatic patients 2, 3.
- Lifestyle Modifications: Lifestyle modifications, including stopping smoking, monitoring hypertension, hyperlipidemia, and diabetes, are also crucial in managing carotid stenosis 2, 4.
- Revascularization Procedures: Revascularization procedures, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS), may be considered in certain cases, including symptomatic patients with stenosis >50% and asymptomatic patients with tight stenosis (>60%) and a perceived high long-term risk of stroke 4, 5.
Asymptomatic Carotid Stenosis
In asymptomatic carotid stenosis, the risk of disease progression is higher in patients receiving dual antiplatelet therapy and smokers 6. The use of aspirin (81-325 mg daily) is still reasonable for prevention of vascular events in these patients 3.
Symptomatic Carotid Stenosis
In symptomatic carotid stenosis, intensive medical therapy, including the use of dual antiplatelet therapy with aspirin and clopidogrel for the first 90 days following the ischemic event, is recommended 4. Revascularization procedures, such as CEA or CAS, may be considered in these patients, depending on several factors, including the patient's anatomy, age, gender, and procedural risk 4, 5.
Perioperative Antithrombotic Therapy
Perioperative antithrombotic therapy, including aspirin and clopidogrel, is recommended in patients undergoing CEA or CAS 2, 4. The choice of procedure may be influenced by anatomy, prior illness or treatment, or patient risk 5.