Management of Old Cerebral Infarcts

Diagnostic Evaluation

Vascular imaging of both intracranial and extracranial vessels must be performed to identify treatable causes and guide secondary prevention, according to the American College of Radiology 2 and Stroke guidelines 1
Obtain CTA, MRA, or carotid duplex ultrasound to assess for carotid stenosis requiring revascularization, intracranial atherosclerotic disease, vertebrobasilar disease, and unstable plaque or other culprit lesions in cryptogenic cases, as recommended by the American College of Radiology 2 and Stroke guidelines 1, 3
Perform cardiac evaluation with echocardiography to detect atrial fibrillation or flutter, patent foramen ovale, left ventricular thrombus, and valvular disease, endocarditis, or cardiac tumors, according to Stroke guidelines 1
Extended cardiac monitoring detects atrial fibrillation in 16.1% of cryptogenic stroke patients versus 3.2% with standard monitoring, as reported by Stroke guidelines 1

Initiate antiplatelet therapy immediately unless atrial fibrillation or another indication for anticoagulation is identified, according to Stroke guidelines 1
Aspirin 81-325 mg daily is the foundation of antiplatelet therapy, and consider dual antiplatelet therapy for high-risk patients, as recommended by Stroke guidelines 1
Switch to anticoagulation if atrial fibrillation is detected on extended monitoring, according to Stroke guidelines 1
Target blood pressure <130/80 mmHg, and use ACE inhibitors or angiotensin receptor blockers as preferred agents, with evidence suggesting improved survival and reduced vascular events, as recommended by Stroke guidelines 1 and the American Heart Association 4, 5
High-intensity statin therapy is recommended regardless of baseline LDL, according to Stroke guidelines 1
Target HbA1c <7% with appropriate glucose-lowering agents, according to Stroke guidelines 1
Lifestyle modifications include smoking cessation, weight reduction if BMI >25, regular aerobic exercise, and a Mediterranean-style diet, as recommended by Stroke guidelines 1

Do not order follow-up brain MRI routinely, but repeat imaging is indicated only for new symptoms, not for surveillance of old infarcts, as recommended by the Journal of the American College of Radiology 3
Do not delay vascular imaging, and identifying carotid stenosis or atrial fibrillation fundamentally changes management and can prevent devastating recurrent strokes, according to the American College of Radiology 2 and Stroke guidelines 1
Do not rely on standard 24-hour Holter monitoring alone, and extended cardiac monitoring is required to adequately screen for paroxysmal atrial fibrillation in cryptogenic cases, according to Stroke guidelines 1