CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
AFRICA
e13
anesthesia, hypostenia and plegias, thoracic dolor, dyspnoea
episodes, lower-limb claudication), and echo colour Doppler
analysis of the SATs. At one-year follow up, the patient was still
asymptomatic and in a satisfactory physical condition.
Discussion
Atherosclerotic disease represents the leading cause of death
and morbidity in industrialised nations. It is a chronic, systemic
disease that may involve multiple vascular areas at the same
time; not only the coronary arteries, but also the peripheral
vessels, particularly the SATs, namely carotid and vertebral
arteries in their extra-cranial portions, the lower limbs, renal,
hypogastric and mesenteric arteries. The most important impact
of atherosclerosis on mortality and morbidity after myocardial
ischaemia is due to cerebrovascular disease.
Stroke is the third cause of mortality and the leading cause of
long-term disability in the Western world. In 80% of cases it is
due to cerebral ischaemia, while the haemorrhagic type accounts
for only 15–20% of the total number of strokes.
2,3
Extra-cranial
atherosclerotic occlusions account for 15–20% of all ischaemic
strokes, while atheromatous lesions of the intracranial vessels
are rarely responsible for cerebral infarction. Carotid occlusions
are more frequently responsible for the genesis of a stroke,
however one-quarter of ischaemic strokes involve the posterior
circulation, and stenosis of the VA may account for up to 20% of
posterior circulation ischaemic strokes.
For all these reasons, treatment of SATs atherosclerosis
is crucial to prevent stroke. The mainstay of treatment is the
optimisation of medical therapy for primary and secondary
prevention of cardiovascular accidents and, if necessary, surgical
or endovascular revascularisation. Non-invasive management
includes removal and treatment of atherosclerosis risk factors
such as smoking, hypertension, dyslipidaemia and diabetes.
A significant reduction in mortality from stroke has been
demonstrated with anti-hypertensive therapy to values below
140/90 mmHg, statin-based lipid-lowering therapy, and an
adequate hypoglycaemia regimen.
2-4
Another cornerstone of medical treatment is antiplatelet
therapy with aspirin and, in high-risk patients, clopidogrel,
dipyridamole and ticlodipine, not only as secondary prevention,
but also in patients with evidence of an atherosclerotic occlusion
of the carotid or vertebral circulation, with or without ischaemic
symptoms. The purpose of this medical approach is to decrease
global cardiovascular risk, not only the risk of a cerebrovascular
accident. An invasive approach, on the other hand, acts on a
specific lesion, restoring the patency of the vascular lumen
and reducing the potential hazards due to the presence of an
atheromatous plaque such as thrombosis, thrombo-embolism
and intra-plaque haemorrhage.
With regard to carotid stenosis, the gold standard has for
many years been surgical treatment (carotid endarterectomy,
CEA), however in the last two decades endovascular stenting of
carotid lesions (CAS) has joined surgery as a valid therapeutic
alternative, with specific benefits and unfavourable aspects.
Recently, the equivalence of these two approaches has been
clearly demonstrated in the CREST trial.
5
A
B
Fig. 1. A: Volume-rendering reconstruction of contrast-enhanced MRA shows significant stenosis of the brachioce-
phalic trunk (o), occlusion of the left origin of the subclavian artery (*), thrombosis of the ICA bilaterally (
→
), and steno-
sis of both vertebral arteries at the origin of the subclavian artery (
>
). B: Volume-rendering reconstruction of TOF3D
MRA shows regular vessel flow of the proximal and distal tract of the Willis circle, with hypertrophic compensatory
posterior communicating arteries (pCoA) bilaterally. The intracavernous tract of the ICA is not visible bilaterally.
Fig. 2. A: Fast-spin echo T2w axial scan shows regular
morphology and appearance of brain parenchyma. B: EPI
FFE T2* perfusion map shows regular and symmetrical
rCBV of the cerebral anterior and posterior circulation.
The artifact in the frontal area is due to the patient’s oral
prosthesis.
A
B
