Preventing Stroke in Patients with Small Chronic Peripheral Infarcts

Risk Assessment and Diagnosis

MRI with diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences is the gold standard for assessing ischemic core and should be used to confirm the presence and extent of MCA territory infarcts, as recommended by the American Heart Association 1, 2
Multiple small cortical infarcts located in the MCA territory and vascular border-zone areas are typical findings in embolic stroke arising from carotid disease, with a high risk of recurrent stroke 1
Silent brain infarctions on cerebral imaging are associated with a two-fold increased risk of future stroke, requiring aggressive preventive measures, according to the American College of Cardiology 1

Antiplatelet therapy is uniformly recommended by major guidelines, such as the American College of Cardiology, for secondary stroke prevention 3

Target systolic blood pressure control <120 mm Hg as recommended by guidelines, such as the American Heart Association, to reduce the risk of recurrent stroke 3
Angiotensin-converting enzyme inhibitors are preferred antihypertensive agents for stroke prevention, as recommended by the American College of Cardiology 3

Duplex ultrasound scanning should be performed to identify potential carotid stenosis, which is a common cause of MCA territory infarcts, as recommended by the Society for Vascular Surgery 1
For asymptomatic patients with carotid stenosis >60-70%, intervention (endarterectomy or stenting) should be considered, according to the American College of Cardiology 1
For symptomatic patients with carotid stenosis >50%, intervention is recommended as the risk of recurrent stroke rises sharply with the degree of stenosis, as recommended by the American Heart Association 1

Weight management and dietary modifications should be implemented to control vascular risk factors, as recommended by the American College of Cardiology 3

Patients with evidence of small chronic peripheral infarcts in the right MCA territory should be evaluated for atrial fibrillation with 12-lead ECG and consider prolonged Holter monitoring, as recommended by the American Heart Association 3
For patients with evidence of cardioembolism (particularly atrial fibrillation), anticoagulation rather than antiplatelet therapy should be considered, according to the American College of Cardiology 3
Patients with multiple risk factors may benefit from dual pathway blockade, particularly those with concomitant coronary or peripheral artery disease, as recommended by the American College of Cardiology 3

Regular neuroimaging follow-up may be necessary to monitor for new silent infarctions, which are associated with increased stroke risk, as recommended by the American College of Radiology 1
Monitor for hemorrhagic transformation, which is a common complication in patients with severe stroke, although this fact is from Praxis Medical Insights, a similar recommendation can be found from the Neurocritical Care Society 4