New Standards of Care in Ischemic Stroke

Background: Ischemic arterial strokes of the ophthalmic artery and its branches and posterior cerebral artery are common causes of visual disability. Etiologies of stroke affecting the retina, optic nerve, optic radiation, and visual cortex overlap with other types of ischemic strokes. Stenosis of the internal carotid is the most common cause of central retinal artery occlusion (CRAO). One-fourth of patients with CRAO have cerebral strokes. We report recent developments in the acute treatment and secondary prevention of ischemic stroke of relevance to clinicians who encounter patients with acute vision loss. Evidence Acquisition: A search of Pubmed and practice guidelines over the past 5 years was performed, with a focus on significant changes in treatment and prevention of ischemic stroke. Results: Recent randomized controlled trials provide Level I evidence for the use of endovascular therapy with current stent retriever devices for patients with large vessel anterior circulation occlusions within 6 hours of presentation. Number needed to treat to achieve one additional patient with an independent functional outcome was in the range of 3-7, and benefit was additive to that of intravenous tissue plasminogen activator alone. Paroxysmal atrial fibrillation (AF) is a major cause of cryptogenic stroke with incidence expected to rise with the aging population. Since 2014, prolonged 30-day cardiac monitoring has been recommended as a part of transient ischemic attack and stroke workup in patients with cryptogenic stroke. Even longer term monitoring of 6 months to 1 year with external and implantable loop recorders improves rates of diagnosing AF. First available in 2010, the novel anticoagulants-dabigatran, apixaban, rivaroxaban, and edoxaban-have been compared with warfarin in the prevention of stroke in patients with nonvalvular AF. Apixaban demonstrated superiority in safety and efficacy, with the novel anticoagulants as a group having favorable risk-benefit profile at higher dosages compared with standard warfarin therapy. Conclusions: Endovascular therapy is now standard of care for eligible patients with anterior large vessel occlusions. Prolonged cardiac monitoring is recommended for patients with cryptogenic stroke. The novel anticoagulants are an alternative to warfarin in patients with AF. (C) 2016 by North American Neuro-Ophthalmology Society