This chapter reviews the causes and treatments of cerebrovascular disease with regard to antithrombotic therapy. Included are discussions regarding the etiology and pathogenesis of stroke, the role of antithrombotic medications in the treatment and prevention of stroke, and the evidence for the use of individual agents. Finally, a basic algorithm for the treatment of stroke with regard to choice of antithrombotic agents is presented.
WHAT MAKES CEREBROVASCULAR DISEASE UNIQUE?
Although cerebrovascular disease has much in common with cardiovascular and peripheral arterial disease, there are several elements of its etiology, evaluation, and therapy that set it apart. First, strokes can be and frequently are hemorrhagic. Strokes that begin as ischemic events can also become hemorrhagic. These hemorrhages can have a devastating effect on the patient and thus must be considered very carefully before proceeding with powerful antithrombotic medications. Second, even very small strokes can have a devastating effects. Practically speaking, this means that small artery disease can play a large role in stroke morbidity, in contrast to the more frequent large artery pathology seen in myocardial infarction (MI) and peripheral arterial disease. Third, unlike coronary and peripheral arteries, the arteries of the brain are often not amenable to mechanical intervention. Although a patient with coronary artery disease may have bypass surgery, stenting, or angioplasty to repair an occluded or stenotic artery and a peripheral arterial patient may have bypass, endarterectomy, or clot removal surgery, these techniques are much less widely accepted in cerebrovascular disease.