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Two Upstate neurologists among authors of new guideline for stroke prevention in some patients

Two Upstate Medical University doctors are among a team of doctors nationwide that are authors of a new practice advisory for the American Academy of Neurology.

Upstate professors of neurology Antonio Culebras, MD, and Julius Latorre, MD, MPH, are among 19 professionals who researched and wrote the new guideline, which was recently published in the AAN Journal ( https://n.neurology.org/content/98/12/486)

The guideline states that the use of medications to prevent blot clots, reduce blood pressure and cholesterol, along with safe levels of exercise, are as good as and may be more beneficial at preventing a second stroke in people with symptomatic intracranial atherosclerosis than placing a stent in the blood vessel or doing bypass surgery.

“This is an important guideline because it highlights that aggressive medical management works,” Latorre said. “It is a win-win for everyone. People always think surgery is better than just taking pills. In this particular disease, we know that medical management works. We don’t have any surgery or procedure currently that consistently helps this condition other than best medical management. That’s the key message here.”

Annually, 2.5 million people worldwide and 800,000 people in the United States have strokes. Intracranial atherosclerosis is one type of stroke where plaque builds up in the arteries that supply blood to the brain, causing these vessels to narrow and get blocked. Culebras said intracranial atherosclerosis is more prevalent among Asian, Black, Latin American and American Indian populations.

“Specifically, 1 out of 4 strokes are recurring strokes, which means that they are preventable,” Latorre said. “We now have a lot more evidence at our disposal that supports a treatment regime that does not require any special intervention.”

Culebras said initial work on this guideline began in 2014, when he was chair of the stroke and vascular section of the AAN. He advocated to have Upstate faculty members be a part of this process. Another author of the study, Rajbeer S. Sangha, was at Upstate at the time.   

To begin the process, staff at the AAN selected 3,500 articles. The guideline authors reviewed 620 of them and then selected 56 to be included as scientific evidence into the new advisory. The final review of those articles started in early 2020.

Culebras said the groundwork for this guideline grew out of research trials run by the National Institute of Neurological Disorders and Stroke (NINDS)  looking into the best medical treatment for intracranial atherosclerosis. He was a local co-investigator in that trial, which determined that aspirin works better than blood thinners. That evolved into looking at different interventions such as angioplasty. Those results were published in the New England Journal of Medicine.

“As a result, the next step was to create a guideline,” Culebras said. “That sequence of events started 20 to 25 years ago. These things go very slowly because the evidence has to be found. Once the evidence is revealed, confirmed and accepted, then the guidelines are put together.

“As you can imagine a guideline of this nature requires a lot of time, so I expect the recommendations of this guideline will remain uncontested for the next decade,” Culebras said.

He said that it makes intuitive sense to put a catheter into narrowing arteries, however, that procedure comes with many other risks and complications “That’s what the science in this guideline is telling us,” he said. “That medical treatment for this particular form of arterial stenosis is to be recommended over any kind of intervention. This guideline is very specific. Medication, medication, medication. “


Caption: Antonio Culebras, MD, and Julius Latorre, MD.