[Prevention of cerebral infarct caused by atherosclerosis]

Atherosclerosis of the cerebral arteries is the main cause of cerebral infarction but the frequency with which this cause is implicated is very variable from one trial to another depending on the criteria used. Primary prevention of this type of infarction is mostly based on the correction of arterial risk factors and on carotid artery surgery in selected cases. Aspirin does not appear to the effective in this indication. The respective indications of heparin and aspirin in the acute phase of cerebral infarction remain controversial despite the recent publications of large scale therapeutic trials. The benefits of these treatments is, at best, globally modest. Thrombolytics could, on the other hand, revolutionize the treatment of acute cerebral infarction if the encouraging results of a recent trial using rt-PA in the first 3 hours, are confirmed by other trials. After the acute phase, antiplatelet agents (aspirin, ticlopidine, clopidogrel or aspirin associated with dipyridamole) and surgery in patients with symptomatic carotid artery stenosis greater than 50% or 70-80% (according to the method of measurement) have been shown to be effective. Several large scale trials are under way to assess the benefits and risks: a) of antihypertensive therapy in patients with previous cerebrovascular accidents, b) of treatment with statins of patients at high risk of infarction due to atherosclerosis, c) of oral anticoagulants at low dosage (versus antiplatelet agents) in secondary prevention, d) of thrombolytics in the acute phase of cerebral infarction, e) of carotid angioplasty (versus surgery) in patients with symptomatic severe stenosis.