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[Anticoagulants: when, which, how much, until when: these are still the questions.II]
1Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina. cjestol@infovia.com.ar
Insights
This study proposes treatment algorithms for ischemic cerebrovascular disease, emphasizing individualized anticoagulation strategies based on etiology and mechanism for better patient outcomes.
Area of Science:
- Neurology
- Vascular Medicine
Context:
- Ischemic cerebrovascular disease presents with diverse clinical manifestations.
- Effective treatment requires understanding specific etiological factors like aorto-embolic and cardio-embolic events.
Purpose:
- To analyze varied presentations of ischemic cerebrovascular disease.
- To develop tailored treatment algorithms, particularly for anticoagulation.
- To assess therapeutic options for hemorrhagic infarcts.
Summary:
- Reviews clinical, diagnostic, and therapeutic features of aorto-embolic and cardio-embolic cerebrovascular disease.
- Suggests a treatment algorithm for anticoagulation, detailing timing, selection, dosage, administration, and duration.
- Evaluates management strategies for hemorrhagic infarcts.
Impact:
- Highlights the need for etiology-specific treatments over generalized 'stroke' management.
- Proposes individualized treatment parameters based on 40 years of clinical experience and literature review.
- Aims to improve therapeutic efficacy by defining distinct cerebrovascular scenarios.
Objective:
To analyze the different presentations of ischemic cerebrovascular disease and develop algorithms for treatment in those different possible settings.
Development:
We present an analysis of the publications in which the clinical, diagnostic and therapeutic features of aorto-emboli and cardio-emboli (patent foramen ovale, septal aneurysm, bacterial endocaritis, etc.) have been defined. We suggest an algorithm with general parameters for the use of anticoagulants in cerebrovascular disease. Subsequently we specifically consider the decision as to the moment to start anticoagulation, selection of the type of anticoagulant, dosage, route of administration and duration of the treatment. Because of the implications for treatment, we assess the therapeutic options when haemorrhagic infarcts occur.
Conclusions:
Based on studies in the literature showing benefit in individualized cerebrovascular disorders, and the anecdotic experiences of Drs. Miller Fisher, Caplan, Pessin and the writer, over the past 40 years using anticoagulants in the different clinical settings described, some parameters for treatment are proposed. We emphasize that whilst patients with different types of cerebrovascular disease are all grouped together under the unifying term 'stroke', the various treatments evaluated will probably be shown to be inefficient or deleterious. The line of treatment suggested in this review is based on the definition of the different cerebrovascular scenarios according to their aetiology and mechanisms, so as to obtain the most suitable treatment in each case.