[Prevention of cerebrovascular disorders]

The decision for the optimal preventive and therapeutic interventions in cerebrovascular disease depends on the underlying disease process. Therefore it is important to identify the different pathomechanisms by modern techniques. The significantly increased cardiovascular risk of patients with atherosclerotic extracranial arterial disease--even when neurologically asymptomatic--makes identification and elimination of all vascular risk factors of crucial importance for primary and secondary prevention. The low risk of stroke without prior transient ischemic attacks makes prophylactic carotid surgery not advisable in asymptomatic patients. Regular controls by sonography are necessary to identify patients with progression of carotid stenosis, and the patients should be informed about warning symptoms of threatening stroke. Secondary prevention with antiplatelet agents (aspirin, ticlopidine) proved effective in patients with cerebrovascular diseases by significant reduction in mortality and in the incidence of stroke and myocardial infarction. The optimum dose of aspirin is not known. Patients with atherosclerotic lesions of the major cerebral arteries have not been shown convincingly to benefit from long-term anticoagulation, while the risk of bleeding complications is increased significantly. Major clinical trials have been initiated to evaluate the benefit of carotid endarterectomy. Anticoagulation therapy can reduce the risk of cardiogenic emboli. Recently it was demonstrated that also aspirin seems effective in reducing incidence of thromboembolic complications in patients with chronic atrial fibrillation. The start of anticoagulant therapy after cerebral embolism depends mainly on CT scan findings.