What is the rationale for the acute use of anticoagulant therapy in posterior cerebral artery (PCA) stroke?

Answer

The rationale for the acute use of anticoagulant therapy lies in preventing acute recurrence of stroke; however, trials have shown that this risk of early recurrent stroke is low and that heparin does not provide any functional or survival advantage. Nonetheless, this remains a controversial area, with some stroke experts having strong opinions about acute anticoagulation.

In general, the stroke mechanism should be identified so that a better, informed decision can be made before long-term anticoagulation is chosen. PCA strokes that arise from vertebral artery dissection are more frequently treated with anticoagulation, although again there is a paucity of data to support this use.

Early anticoagulation may be the most appropriate preventive strategy in specific circumstances that are considered high-risk, such as the presence of an intracardiac thrombus or a dissection with visualized large intraluminal thrombus. Strokes caused by atrial fibrillation do not require early anticoagulation with heparin. Studies have demonstrated that the risk of recurrent stroke within the first weeks is approximately 1%.^[24]Early heparinization in this setting is associated with no clear stroke prevention benefit but is associated with increased hemorrhagic complications.

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

Adams DS. Stroke rehabilitation: indications, outcomes, recent developments. J La State Med Soc. 1996 Nov. 148(11):498-502. [Medline].
Arboix A, Arbe G, García-Eroles L, Oliveres M, Parra O, Massons J. Infarctions in the vascular territory of the posterior cerebral artery: clinical features in 232 patients. BMC Res Notes. 2011 Sep 7. 4:329. [Medline]. [Full Text].
Kwon JY, Kwon SU, Kang DW, Suh DC, Kim JS. Isolated lateral thalamic infarction: the role of posterior cerebral artery disease. Eur J Neurol. 2012 Feb. 19(2):265-70. [Medline].
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001 Jun 13. 285(22):2864-70. [Medline].
Yamamoto Y, Georgiadis AL, Chang HM, Caplan LR. Posterior cerebral artery territory infarcts in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 1999 Jul. 56(7):824-32. [Medline].
Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D'Este C, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011 Nov 12. 378(9804):1699-706. [Medline].
Brandt T, Steinke W, Thie A, Pessin MS, Caplan LR. Posterior cerebral artery territory infarcts: clinical features, infarct topography, causes and outcome. Multicenter results and a review of the literature. Cerebrovasc Dis. 2000 May-Jun. 10(3):170-82. [Medline].
Devinsky O, Bear D, Volpe BT. Confusional states following posterior cerebral artery infarction. Arch Neurol. 1988 Feb. 45(2):160-3. [Medline].
Capitani E, Laiacona M, Pagani R, Capasso R, Zampetti P, Miceli G. Posterior cerebral artery infarcts and semantic category dissociations: a study of 28 patients. Brain. 2009 Apr. 132:965-81. [Medline].
Barbeau H, Norman K, Fung J, Visintin M, Ladouceur M. Does neurorehabilitation play a role in the recovery of walking in neurological populations?. Ann N Y Acad Sci. 1998 Nov 16. 860:377-92. [Medline].
Goehre F, Jahromi BR, Hernesniemi J, Elsharkawy A, Kivisaari R, von Und Zu Fraunberg M, et al. Characteristics of posterior cerebral artery aneurysms: an angiographic analysis of 93 aneurysms in 81 patients. Neurosurgery. 2014 Aug. 75(2):134-44; discussion 143-4; quiz 144. [Medline].
Hanlon RE, Dobkin BH, Hadler B, Ramirez S, Cheska Y. Neurorehabilitation following right thalamic infarct: effects of cognitive retraining on functional performance. J Clin Exp Neuropsychol. 1992 Jul. 14(4):433-47. [Medline].
Hassid EI. Neuropharmacological therapy and motor recovery after stroke. Mil Med. May 1995. 160(5):223-6.
Rose FD, Brooks BM, Attree EA, Parslow DM, Leadbetter AG, McNeil JE, et al. A preliminary investigation into the use of virtual environments in memory retraining after vascular brain injury: indications for future strategy?. Disabil Rehabil. 1999 Dec. 21(12):548-54. [Medline].
Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009 Aug. 40(8):2945-8. [Medline]. [Full Text].
Rothwell PM. Is intravenous recombinant plasminogen activator effective up to 4.5 h after onset of ischemic stroke?. Nat Clin Pract Cardiovasc Med. 2009 Mar. 6(3):164-5. [Medline].
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25. 359(13):1317-29. [Medline].
Wahlgren N, Ahmed N, Dávalos A, Hacke W, Millán M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. 2008 Oct 11. 372(9646):1303-9. [Medline].
Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 May. 38(5):1655-711. [Medline]. [Full Text].
Kim YB, Lee JW, Huh SK, Kim BM, Kim DJ. Outcomes of multidisciplinary treatment for posterior cerebral artery aneurysms. Clin Neurol Neurosurg. 2013 Oct. 115(10):2062-8. [Medline].
The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. N Engl J Med. 1985 Nov 7. 313(19):1191-200. [Medline].
Sandercock PA, Gibson LM, Liu M. Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack. Cochrane Database Syst Rev. 2009 Apr 15. CD000248. [Medline].
Sandercock PA, Counsell C, Kamal AK. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev. 2008 Oct 8. CD000024. [Medline].
Hallevi H, Albright KC, Martin-Schild S, Barreto AD, Savitz SI, Escobar MA, et al. Anticoagulation after cardioembolic stroke: to bridge or not to bridge?. Arch Neurol. 2008 Sep. 65(9):1169-73. [Medline]. [Full Text].
Amarenco P, Bogousslavsky J, Callahan A 3rd, Goldstein LB, Hennerici M, Rudolph AE, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006 Aug 10. 355(6):549-59. [Medline].
de Monyé C, Dippel DW, Siepman TA, Dijkshoorn ML, Tanghe HL, van der Lugt A. Is a fetal origin of the posterior cerebral artery a risk factor for TIA or ischemic stroke? A study with 16-multidetector-row CT angiography. J Neurol. 2008 Feb. 255(2):239-45. [Medline].
Finelli PF. Neuroimaging in acute posterior cerebral artery infarction. Neurologist. 2008 May. 14(3):170-80. [Medline].
Gustafsson D, Elg M. The pharmacodynamics and pharmacokinetics of the oral direct thrombin inhibitor ximelagatran and its active metabolite melagatran: a mini-review. Thromb Res. 2003 Jul 15. 109 Suppl 1:S9-15. [Medline].
Hasso AN, Stringer WA, Brown KD. Cerebral ischemia and infarction. Neuroimaging Clin N Am. 1994 Nov. 4(4):733-52. [Medline].
Kapoor K, Singh B, Dewan LI. Variations in the configuration of the circle of Willis. Anat Sci Int. 2008 Jun. 83(2):96-106. [Medline].
Kwak JH, Choi JW, Park HJ, Chae EY, Park ES, Lee DH, et al. Cerebral artery dissection: spectrum of clinical presentations related to angiographic findings. Neurointervention. 2011 Aug. 6(2):78-83. [Medline]. [Full Text].
NINDS and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995 Dec 14. 333(24):1581-7. [Medline].
Steinke W, Mangold J, Schwartz A, Hennerici M. Mechanisms of infarction in the superficial posterior cerebral artery territory. J Neurol. 1997 Sep. 244(9):571-8. [Medline].
Sylaja PN, Puetz V, Dzialowski I, Krol A, Hill MD, Demchuk AM. Prognostic value of CT angiography in patients with suspected vertebrobasilar ischemia. J Neuroimaging. 2008 Jan. 18(1):46-9. [Medline].
Wahlgren N, Ahmed N, Dávalos A, Hacke W, Millán M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. 2008 Oct 11. 372(9646):1303-9. [Medline].

Media Gallery

Unenhanced head computed tomography (CT) scan demonstrating a subacute L posterior cerebral artery (PCA) infarct.
Unenhanced head computed tomography (CT) scan demonstrating hemorrhagic conversion of an ischemic stroke, approximately 72 hours after symptom onset.
Brain magnetic resonance imaging (MRI) scan demonstrating acute stroke. Diffusion restriction is seen on diffusion-weighted imaging.
Magnetic resonance (MR) angiogram demonstrating bilateral fetal posterior cerebral artery (PCA) variants (black arrows) with the basilar artery terminating in bilateral superior cerebellar arteries (blue arrows).
Digital subtraction angiogram demonstrating an acute L posterior cerebral artery (PCA) occlusion (red arrow) following balloon-assisted coiling of a basilar tip aneurysm.
Digital subtraction angiogram demonstrating revascularization of acute L posterior cerebral artery (PCA) occlusion (red arrow) during a balloon-assisted basilar tip aneurysm revascularization with use of balloon angioplasty.
Computed tomography (CT) scan of the brain showing hypodense areas in the right occipital lobe consistent with a recent posterior cerebral artery (PCA) ischemic infarct.

of 7

Author

Erek K Helseth, MD Fellow, Vascular and Interventional Neurology, Oregon Health and Science University School of Medicine

Erek K Helseth, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Executive Committee for the NINDS-funded DEFUSE3 Trial; Physician Advisory Board for Coherex Medical.

Acknowledgements

Alastair M Buchan, DSc, MBBCh Professor, Head of Medical Sciences Division, University of Oxford, UK