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Neurology 2000;55:490-498
© 2000 American Academy of Neurology
Articles

Symptomatic intracranial atherosclerosis

Outcome of patients who fail antithrombotic therapy

Vincent N. Thijs, MD and Gregory W. Albers, MD

From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University Medical Center, Palo Alto, CA.

Address correspondence and reprint requests to Dr. V.N. Thijs, Stanford Stroke Center, Stanford University Medical Center, 701 Welch Rd., Bldg. B, Suite 325, Palo Alto, CA 94304-0117; e-mail: vthijs{at}stanford.edu

OBJECTIVE: To determine the prognosis of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy.

BACKGROUND: The outcome of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy is unknown. These patients may represent the target group for investigation of more aggressive therapies such as intracranial angioplasty.

METHODS: The authors performed a chart review and telephone interview of patients with symptomatic intracranial atherosclerosis identified in the Stanford Stroke Center clinical database. A Cox regression model was created to identify factors predictive of failure of antithrombotic therapy. The authors generated Kaplan–Meier survival curves to determine the timing of recurrent TIA, stroke, or death after failure of antithrombotic therapy.

RESULTS: Fifty-two patients had symptomatic intracranial atherosclerosis and fulfilled entry criteria. Twenty-nine of the 52 patients (55.8%) had cerebral ischemic events while receiving an antithrombotic agent (antiplatelet agents [55%], warfarin [31%], or heparin [14%]). In a Cox regression model, older age was an independent predictor of failure of antithrombotic therapy, and warfarin use was associated with a decrease in risk. Recurrent TIA (n = 7), nonfatal/fatal stroke (n = 6/1), or death (n = 1) occurred in 15 of 29 (51.7%) of the patients who failed antithrombotic therapy. The median time to recurrent TIA, stroke, or death was 36 days (95% CI 13 to 59).

CONCLUSIONS: Patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy have extremely high rates of recurrent TIA/stroke or death. Recurrent ischemic events typically occur within a few months after failure of standard medical therapy. The high recurrence risk observed warrants testing of alternative treatment strategies such as intracranial angioplasty.




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