General Internal Medicine

Vascular Neurology

Questions discussed in this category

In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?

How would you adjust statin therapy in these patients?

4 Answers available

When do you consider attributing isolated psychosis to an acute ischemic stroke?

1 Answer available

Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?

2 Answers available

How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?

Is treatment indefinite or do you consider discontinuing chronic transfusions at some threshold?

2 Answers available

Do you recommend any medical management for patients with evidence of intracranial atherosclerosis without evidence for stroke?

2 Answers available

In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?

1 Answer available

What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?

New data suggests monoclonal gammopathies can be associated with thrombotic events. Is your practice changing to include monoclonal gammopathy evaluat...

1 Answer available

At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?

2 Answers available

For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?

What is the duration of each treatment choice and which drug is preferred by either group? What else should we take into consideration when deciding o...

2 Answers available

Would you recommend dual antiplatelet therapy or anticoagulation for a patient previously on aspirin who has a breakthrough stroke with history of CADASIL?

2 Answers available

What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?

3 Answers available

What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?

Is there any utility in predominantly venous hypercoagulability labs?

7 Answers available

Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?

For example, would you consider this method in an ESRD/HD patient with antiphospholipid syndrome who had a major bleed requiring reversal of warfarin ...

4 Answers available

Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?

Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...

1 Answer available

What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?

In light of a publication by Sakusic et al., PMID 39102615 suggests an increased risk of ICH expansion in patients with heparin bridge compared to sta...

1 Answer available

When should one consider obtaining a cardiac MRI in ischemic stroke patients?

What is the utility of it?

2 Answers available

What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?

6 Answers available

How do you use cardiac biomarkers, if at all, in prognostication for patients with ischemic stroke?

In light of data from Chang et al in J Neurol Aug 2024 showing that biomarkers such as LDH and troponin were associated with adverse clinical outcomes...

0 Answers available

What treatment do you use for stroke prevention in cervical artery dissection?

In light of the STOP-CAD study

2 Answers available

For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?

It seems clear that longer monitoring yields more AF detected. What is less clear to me is whether all ILR-detected AF is relevant and merits anticoag...

4 Answers available

How do you treat patients with stroke thought to be secondary to Lambl excrescence?

2 Answers available

How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?

Would you recommend left atrial appendage occlusion with or without continuing anticoagulation? In light of Maarse et al., JAMA Neurology 2024.

3 Answers available

When do you consider starting short-term DAPT in patients who present more than 24 hours after the onset of a high-risk TIA or minor stroke syndrome?

In light of the INSPIRES trial publication.

4 Answers available

How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?

How do you balance between having a higher long-term blood pressure to prevent flow failure and leading to worsening of stenosis or occlusion from the...

2 Answers available

Does aspirin dose (81 mg vs 325 mg) matter for secondary stroke prevention?

Should some patients get 325 mg instead of 81mg at least for a certain amount of time, such as patients in the acute phase of ischemic stroke or patie...

1 Answer available

Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?

1 Answer available

Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?

If yes, if the assay shows they are a non-responder, do you switch to ticagrelor?

2 Answers available

How would you best evaluate and manage a patient with hemiplegic migraine and a history of ischemic stroke?

1 Answer available

How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?

Would you consider using cilostazol instead of antiplatelets?

1 Answer available

When do you consider stenting in patients with recurrent stroke with ICAD?

2 Answers available

What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?

1 Answer available

When would you consider neuro-stimulants in post-stroke patients?

Is there management guidance on when to start after stroke onset?

3 Answers available

When is brain biopsy useful/warranted as part of the diagnostic work-up in patients with suspected primary CNS angiitis?

3 Answers available

When do you use MRI to evaluate patients with spontaneous subdural hemorrhage?

In light of the evidence associating cerebral amyloid angiopathy (CAA) with subdural hemorrhage; Rivier et al., PMID 38147345.

1 Answer available

Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?

1 Answer available

Do you avoid SSRIs in patients with a history of RCVS?

2 Answers available

When do you re-image patients with a diagnosis of venous sinus thrombosis?

2 Answers available

Would you recommend genetic polymorphic testing before the initiation of antiplatelet medication in patients with ICAD?

4 Answers available

How do you manage incidentally found venous sinus thrombosis?

5 Answers available

Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?

2 Answers available

What criteria are used to choose a specific dose of aspirin in ischemic stroke?

We have seen 81 vs 162 vs 325 mg up to 1300 mg.

3 Answers available

What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?

While some have the practice of 90 days per SAMMPRIS trial, the lower rates of ischemic stroke in the medical therapy group were driven by events with...

8 Answers available

Do you start aspirin for patients with incidentally found intracranial vertebral stenosis?

3 Answers available

When do you restart antiplatelet therapy in patients with hemorrhagic conversion of stroke?

2 Answers available

Would you recommend anti-platelet or anticoagulation in a patient with recurrent strokes, CADASIL, and Antiphospholipid Syndrome?

1 Answer available

Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?

6 Answers available

In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?

Also how would you manage this perioperatively?

7 Answers available

How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?

3 Answers available

In patients with Afib on anticoagulation and concurrent intracranial atherosclerotic disease, would you consider adding an anti-platelet to anticoagulation if there are recurrent events that could be related to the ICAD?

1 Answer available

In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?

Would you anticoagulate if this screening is negative pending PFO closure?

1 Answer available

Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?

Do you distinguish between primary and secondary prevention? Wilson et al., PMID 31130428 is helpful, but curious how people apply this data in practi...

3 Answers available

What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?

1 Answer available

Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?

2 Answers available

When would you consider obtaining a cardiac CT in lieu of standard TEE for the detection of a left atrial appendage thrombus in atrial fibrillation?

2 Answers available

Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?

3 Answers available

What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?

2 Answers available

How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?

1 Answer available

Is LP indicated for patients with recurrent thunderclap headaches over a 4-week period and negative head imaging for SAH?

2 Answers available

What is your practice for the timing of resumption of oral anticoagulation after ICH?

Do you order any imaging beforehand? Are there other studies that you order?

1 Answer available

What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?

Do we prophylactically place patients on anticoagulation after one episode? Besides MRI/MRV brain, are there other diagnostic imaging that should b...

1 Answer available

Does the overall conclusion of the CHANCE-2 trial make ticagrelor + ASA a worthwhile transition given the data showing cumulative hazard of stroke diverged during the first week and was subsequently similar, which suggests the benefit of ticagrelor over clopidogrel is seen predominantly soon after stroke?

4 Answers available

Do you ever do surveillance MR imaging in patients with stable exam and history of cardioembolic stroke?

1 Answer available

Would you generalize the data from the CHANCE-2 trial to a broader clinic population given that the study was specific to Han Chinese patients?

How do you plan to incorporate the results of the CHANCE-2 trial (Wang et al., PMID 34708996) in your own practice?

3 Answers available

Do you recommend genetic testing after a patient on clopidogrel has a stroke based on the results of the CHANCE-2 trial?

3 Answers available

Would you consider anticoagulation for a young patient with a recent embolic stroke and newly diagnosed global cardiac hypokinesis with ejection fraction of less than 25%?

No thrombus detected on echocardiogram and no evidence of atrial fibrillation is present.

1 Answer available

Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?

3 Answers available

How would you approach protein S deficiency found on hypercoagulability work-up in a patient with a post-operative central retinal vein occlusion?

In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...

4 Answers available

How long after starting anticoagulation would you remove an IVC filter in a patient with a DVT presenting with stroke and PFO which is now closed?

1 Answer available

How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?

How do you approach secondary stroke prevention for patients with ischemic stroke, atrial fibrillation, and signs of cerebral amyloid angiopathy/micro...

1 Answer available

Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?

4 Answers available

For patients with atrial fibrillation on DOAC, when should they resume DOAC after a thalamic bleed without intraventricular bleed?

How does presence of intraventricular hemorrhage change your recommendations?

2 Answers available

How do you determine if a patient is safe to drive after having a PCA infarct?

What is the best way to determine if patients with new PCA territory infarct can drive? Upon discharge from the hospital, do you routinely refer them ...

1 Answer available

What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?

Thoughts on sarilumab vs methotrexate, or just treat with steroids alone

1 Answer available

When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?

For example, with a Watchman device? What is the evidence behind this?

1 Answer available

In patients with recurrent ischemic infarcts on the same side as an internal carotid artery lesion, is intervention warranted even if there is less than 50% obstruction?

When would you consider stenting or CEA even if there is less than 50 obstruction when no other etiology has been found?

1 Answer available

Papers discussed in this category

Stroke, 2019-02

Ischemic Stroke and Internal Carotid Artery Web.

J Am Coll Cardiol,

Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.

Neurology, 2015-09-29

Dual antiplatelet therapy in stroke and ICAS: Subgroup analysis of CHANCE.

Stroke, 2017-08

Challenges in the Medical Management of Symptomatic Intracranial Stenosis in an Urban Setting.

Stroke, 2021 May 24

2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association.

Lancet (London, England), 2014-01-25

Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial.

Circulation, 2019-08-20

Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke.

N Engl J Med,

Trial of Tocilizumab in Giant-Cell Arteritis.

Lancet, 2016 Mar 04

Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial.

Arthritis Rheum,

Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis.

American heart journal, 2010-07

Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale.

Lancet, 2021 Aug 27

Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial.

Neurology, 2019 Jan 11

RCVS score and diagnostic approach for reversible cerebral vasoconstriction syndrome.

The New England journal of medicine, 2013-03-21

Closure of patent foramen ovale versus medical therapy after cryptogenic stroke.

Neurology, 2013-08-13

An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke.

The New England journal of medicine, 2017-09-14

Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke.

Circ Cardiovasc Interv, 2022 Jun 23

Transcatheter Closure of Patent Foramen Ovale in Older Patients With Cryptogenic Thromboembolic Events.

JAMA, 2021 Dec 14

Heterogeneity of Treatment Effects in an Analysis of Pooled Individual Patient Data From Randomized Trials of Device Closure of Patent Foramen Ovale After Stroke.

JAMA Neurol, 2020 Jul 01

Proposal for Updated Nomenclature and Classification of Potential Causative Mechanism in Patent Foramen Ovale-Associated Stroke.

JAMA Neurol, 2022 Nov 01

Association of Atrial Septal Aneurysm and Shunt Size With Stroke Recurrence and Benefit From Patent Foramen Ovale Closure.

J Am Heart Assoc, 2020 Nov 23

Direct Oral Anticoagulants in Patients With Inherited Thrombophilia and Venous Thromboembolism: A Prospective Cohort Study.

Am J Hematol,

Protein S abnormalities: a diagnostic nightmare.

Stroke, 2016 Dec 20

Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation.

Stroke, 2010 Oct 28

Optimal timing of resumption of warfarin after intracranial hemorrhage.

J Thromb Haemost, 2010 Apr 08

Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk.

Lancet Neurol, 2021 Sep 03

Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial.

The New England journal of medicine, 2018-07-19

Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.

N Engl J Med, 2013 Jun 26

Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.

N Engl J Med, 2021 Oct 28

Ticagrelor versus Clopidogrel in Loss-of-Function Carriers with Stroke or TIA.

N Engl J Med,

Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.

JAMA neurology, 2019-04-01

Association of Apolipoprotein E With Intracerebral Hemorrhage Risk by Race/Ethnicity: A Meta-analysis.

Lancet Neurol, 2019 May 23

Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

JAMA Neurol,

Assessment of Incidence and Risk Factors of Intracerebral Hemorrhage Among Participants in the Framingham Heart Study Between 1948 and 2016.

Lancet Neurol, 2018 Jan 10

The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy: model development and diagnostic test accuracy study.

Cancer causes & control : CCC, 2010-03

Germline polymorphisms in the one-carbon metabolism pathway and DNA methylation in colorectal cancer.

Atherosclerosis, 2001-06

The 1298A-->C polymorphism in methylenetetrahydrofolate reductase (MTHFR): in vitro expression and association with homocysteine.

The American journal of clinical nutrition, 2008-10

Associations between single nucleotide polymorphisms in folate uptake and metabolizing genes with blood folate, homocysteine, and DNA uracil concentrations.

Circulation. Cardiovascular genetics, 2008-12

Variants of folate metabolism genes and the risk of conotruncal cardiac defects.

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2012-01

Methylenetetrahydrofolate reductase (MTHFR) polymorphism A1298C (Glu429Ala) predicts decline in renal function over time in the African-American Study of Kidney Disease and Hypertension (AASK) Trial and Veterans Affairs Hypertension Cohort (VAHC).

Human genetics, 2012-05

Strong protective effect of the aldehyde dehydrogenase gene (ALDH2) 504lys (*2) allele against alcoholism and alcohol-induced medical diseases in Asians.

PeerJ, 2013

Integrating precision medicine in the study and clinical treatment of a severely mentally ill person.

Nature, 2016-08-18

Analysis of protein-coding genetic variation in 60,706 humans.

Am J Hum Genet, 1998 May

A second common mutation in the methylenetetrahydrofolate reductase gene: an additional risk factor for neural-tube defects?

Am J Reprod Immunol, 2011 Jan 18

Analysis of plasminogen activator inhibitor-1, integrin beta3, beta fibrinogen, and methylenetetrahydrofolate reductase polymorphisms in Iranian women with recurrent pregnancy loss.

Am J Reprod Immunol, 2012 Aug 06