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Table of Contents    
NEUROIMAGES
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 918-919

Symptomatic critical stenosis of the basilar artery treated with enoxaparin


1 Older Persons Rehabilitation Unit, Rotorua Hospital, Rotorua, New Zealand
2 Department of Medicine, Tauranga Hospital, Tauranga, New Zealand

Date of Web Publication5-Jul-2017

Correspondence Address:
Karim M Mahawish
Department of Medicine, Rotorua Hospital, Rotorua
New Zealand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_594_16

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How to cite this article:
Mahawish KM, Lui A. Symptomatic critical stenosis of the basilar artery treated with enoxaparin. Neurol India 2017;65:918-9

How to cite this URL:
Mahawish KM, Lui A. Symptomatic critical stenosis of the basilar artery treated with enoxaparin. Neurol India [serial online] 2017 [cited 2019 Dec 9];65:918-9. Available from: http://www.neurologyindia.com/text.asp?2017/65/4/918/209532




An 80-year old man presented with recurrent episodes of stroke/transient ischemic attacks (TIA) with symptoms, signs, and imaging confirming numerous posterior circulation ischemic strokes [Figure 1]. Angiographic studies demonstrated critical stenosis of the basilar artery [Figure 2]. Despite dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, our patient had a further ischemic stroke. He was commenced on intravenous unfractionated heparin, and subsequently, administered therapeutic doses of enoxaparin, following which he had no further events. Follow-up imaging demonstrated partial recanalization of the basilar artery. After remaining stable for 1 month on enoxaparin, he was converted to DAPT for 2 months, after which aspirin was stopped. His progress continued uneventfully, and at follow-up 4 months later, he was back to normal.
Figure 1: MR DWI sequence demonstrating bilateral posterior fossa acute infarctions

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Figure 2: MR angiogram (Time of Flight) demonstrating critical stenosis of the basilar artery

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Patients presenting with TIA/ischemic stroke should undergo cerebrovascular computed tomography or magnetic resonance angiography to identify the culprit extra- or intracranial stenotic lesions, for whom early aggressive therapy with DAPT is effective and safe. In patients with intracranial arterial stenosis where such treatment fails, options include endovascular stenting or heparin therapy; current data does not support one approach over another. There is no clear guidance on the dose or duration of heparin therapy; however, our strategy of using therapeutic enoxaparin for 1 month, followed by 2 months of dual antiplatelet therapy [thus completing 3 months of intensive therapy as per the stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) trial][1] followed by clopidogrel monotherapy appears effective and safe. We do not promote DAPT for more than 90 days after the initiation of treatment because of the presence of an increased risk of major hemorrhage from the prolonged use of antiplatelet therapy, as has been established in previous trials, e.g., the MATCH (aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients) trial.[2]

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There are no conflicts of interest.



 
  References Top

1.
Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011;365:993-1003.  Back to cited text no. 1
[PUBMED]    
2.
Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): Randomised, double-blind, placebo-controlled trial. Lancet 2004;364: 331-7.  Back to cited text no. 2
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    Figures

  [Figure 1], [Figure 2]



 

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