TRANSIENT ISCHEMIC ATTACK (TIA)
Dual antiplatelet therapy with aspirin and clopidogrel for 90 days after a TIA or stroke due to 70–99% stenosis of an intracranial artery is recommended.
The left atrial appendage is the source of embolism in most patients with atrial fibrillation. Several randomized trials showed percutaneous left atrial appendage closure was equivalent to anticoagulation in preventing stroke and systemic embolization, and several devices are approved for this indication in the United States and Europe. The procedure should be considered in patients with a contraindication to long-term anticoagulation, although short-term anticoagulation (45 days) followed by dual antiplatelet therapy (4.5 months) and then indefinite aspirin monotherapy is usually necessary after device placement.
Kleindorfer DO et al. 2021 Stroke. [PMID: 34024117]
METASTATIC INTRACRANIAL TUMORS
Memantine (5 mg once daily orally titrated by 5 mg weekly to 10 mg twice daily) reduced cognitive toxicity associated with whole-brain radiotherapy in a randomized trial and is recommended; this effect can be augmented through intensity modulated radiation therapy with hippocampal avoidance.
Brown PD et al. J Clin Oncol. [PMID: 32058845]
IDIOPATHIC INTRACRANIAL HYPERTENSION (PSEUDOTUMOR CEREBRI)
Weight loss is important: bariatric surgery led to a decrease in both intracranial pressure and weight at two years compared with a community weight management program in a randomized trial and may be considered in patients with a BMI of 35 or greater.
Mollan SP et al. JAMA Neurol. [PMID: 33900360]
Aducanumab was approved by the FDA despite mixed results in clinical trials. Its use is limited to patients with mild cognitive impairment or mild dementia and amyloid pathology proven by amyloid PET. The ultimate role of this medication is still being debated.
Casimersen is FDA-approved for treatment of Duchenne muscular dystrophy; it shows benefit in patients with a mutation amenable to exon 45 skipping.