Efficacy and Safety of Oral Factor XIa Inhibitors in Stroke Prevention: A Systematic Review and Meta-Analysis

Anticoagulation; Factor Xia inhibitors; Ischemic strokeAnticoagulació; Inhibidors del factor Xia; Ictus isquèmicAnticoagulación; Inhibidores del factor Xia; Ictus isquémicoIntroduction: Despite preventive measures, stroke rates remain high in the primary and secondary prevention settings. Factor XIa inhibition may offer a novel, safe and effective antithrombotic option for stroke prevention. Methods: We conducted a systematic review and meta-analysis including all available randomized controlled clinical trials (RCTs) that investigated the efficacy and safety of factor XIa inhibitors versus controls in primary or secondary stroke prevention. The primary efficacy and safety outcomes of interest were symptomatic ischemic stroke (IS) and the composite of major bleeding and clinically relevant non-major bleeding. Results: Four phase II dose-finding RCTs were included, comprising a total of 4732 patients treated with factor XIa inhibitors versus 1798 controls. Treatment with factor XIa inhibitors did not reduce the risk of IS compared to controls (RR: 0.89; 95% CI: 0.67–1.17). The composite of symptomatic IS and covert infarcts on brain MRI (RR: 1.01; 95% CI: 0.87–1.18), the composite of symptomatic IS and transient ischemic attack (TIA; RR: 0.78; 95% CI: 0.61–1.01), and the composite of major adverse cardiovascular events (RR: 1.07; 95% CI: 0.87–1.31) did not differ between the treatment groups. Treatment with factor XIa inhibitors did not increase the risk of the composite of major bleeding and clinically relevant non-major bleeding (RR: 1.19; 95% CI: 0.65–2.16), major bleeding alone (RR: 1.19; 95% CI: 0.64–2.22), intracranial bleeding (RR: 0.91; 95% CI: 0.26–3.19) or all-cause mortality (RR: 1.21; 95% CI: 0.77–1.90). Conclusion: This meta-analysis provides reassuring evidence regarding the safety of factor XIa inhibitors. These findings, coupled with potential signals of efficacy in reducing IS (and TIA), underscore the importance of ongoing phase III RCTs for providing definitive data regarding the effect of factor XIa inhibition on stroke prevention

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16–2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08–3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26–3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36–25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50–5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65–0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight

Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Introduction: There is uncertainty regarding the optimal timing for initiation of oral anticoagulation in patients with acute ischemic stroke (AIS) due to atrial fibrillation (AF). Methods: We performed a systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) and prospective observational studies to assess the efficacy and safety of early anticoagulation in AF-related AIS (within 1 week versus 2 weeks). A second comparison was performed assessing the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin-K antagonists (VKAs) in the two early time windows. The outcomes of interest were IS recurrence, all-cause mortality, symptomatic intracerebral haemorrhage (sICH) and any ICH. Results: Eight eligible studies (6 observational, 2 RCTs) were identified, including 5616 patients with AF-related AIS who received early anticoagulation. Patients that received anticoagulants within the first week after index stroke had similar rate of recurrent IS, sICH and all-cause mortality compared to patients that received anticoagulation within two weeks (test for subgroup differences p = 0.1677; p = 0.8941; and p = 0.7786, respectively). When DOACs were compared to VKAs, there was a significant decline of IS recurrence in DOAC-treated patients compared to VKAs (RR: 0.65; 95%CI: 0.52-0.82), which was evident in both time windows of treatment initiation. DOACs were also associated with lower likelihood of sICH and all-cause mortality. Conclusions: Early initiation of anticoagulation within the first week may have a similar efficacy and safety profile compared to later anticoagulation (within two weeks), while DOACs seem more effective in terms of IS recurrence and survival compared to VKAs

Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes

Background: The aim of this study in patients with acute posterior ischemic stroke (PS) and atrial fibrillation (AF) were to evaluate the risks of recurrent ischemic event and severe bleeding and these risks in relation with oral anticoagulant therapy (OAT) and its timing. Methods: Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of: stroke recurrence, TIA, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. Results: A total of 2,470 patients were available for the analysis: 473 (19.1%) with PS and 1,997 (80.9%) AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80). Conclusions: Patients with posterior or anterior stroke and AF appear to have similar risks of ischemic or hemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT

Glycemic variability in the acute phase of stroke

Background: Hyperglycemia after acute stroke is a common phenomenon, reported in up to one third of acute stroke patients, affecting both diabetic and non-diabetic patients as well. Admission hyperglycemia has been associated with a pathophysiological sequalae that may lead to poor outcomes in stroke patients, including higher mortality and unfavorable functional recovery post-stroke. In ischemic stroke patients receiving reperfusion therapies, increased glucose values at admission have also been related with lower recanalization rates and higher likelihood of symptomatic intracranial hemorrhage. Therefore, appropriate glucose management in the acute setting was expected to lead to better functional results of the stroke patients. Yet, the results of the randomized-controlled clinical trials in the field did not demonstrate any significant difference in efficacy outcomes among acute stroke patients administered intensive treatment with continuous intravenous insulin compared to the standard of care. On the other hand, the patients receiving intensive treatment showed significantly more hypoglycemic episodes. Investigating other hypoglycemic treatment options that take hypoglycemic risk and glycemic variability into account was thought to be of significant value. Glycemic variability is considered the third component of dysglycemia (along with hyperglycemia and hypoglycemia) but its association with post-stroke outcomes remains only partially elucidated. Methods: A systematic review of the literature and a narrative presentation of studies describing glycemic management in the acute phase of stroke, as well as studies investigating the association between glycemic variability and clinical outcomes post stroke, were conducted. In addition, a prospective follow-up study of 138 patients with acute stroke who were implanted with a continuous glucose monitoring device for up to 96 hours was performed. Thirteen indices of glycemic variability were calculated from the continuous glucose recording data. Clinical outcomes during hospitalization and the follow-up period (90 days) were recorded. Hypoglycaemic episodes revealed by continuous glucose recording device but not detected by finger prick measurements were also recorded. Results: According to the systematic review, glucose management should be started in the first hours after the onset of stroke, preferably within the first 12 hours. Regarding the glucose values that necessitate intervention and the target range to be achieved, it is preferable to adhere to the limits suggested by international recommendations, as tighter glycaemic control was not associated with better outcome but was accompanied by higher rates of hypoglycaemic events. It is also recommended that the duration of treatment should be longer than 48 hours, as the presence of persistent hyperglycaemia and its association with worse outcome is well documented. In addition, a longer duration of hypoglycaemic treatment up to 72 hours is suggested in organised stroke units, whereas the time frame of 120 hours seems to be arduous for nurses without being associated with better clinical outcome. A new potential therapeutic target is glycemic variability, which is calculated from sequential glucose measurements. Higher quality data can be obtained by implementing continuous glucose monitoring in stroke patients. To date, there are limited studies that have evaluated the association between glycaemic variability and clinical outcome after stroke. The continuous glucose monitoring device was successfully implanted in a total of 138 patients with acute stroke (mean age 64±10 years, 61% male, median NIHSS score at admission: 9, IQR: 3-14) after a median duration of 29 hours (IQR: 22-35) from the onset of stroke. Thirty-six (26%) patients were diabetic. The median duration of recording was 78 hours (IQR: 66-92) and provided a total of 115,846 glucose measurements for analysis. None of the indices of glycemic variability were associated with clinical outcomes post-stroke when the complete cohort was analyzed. However, in the subgroup of ischemic stroke patients receiving acute reperfusion therapies, mean glucose, as measured by continuous glucose monitoring, was independently associated with excellent functional outcome at 90 days. Asymptomatic hypoglycaemic episodes were detected in 46 patients (33%) during continuous glucose monitoring; none of these were detected by finger prick measurements. The incidence of hypoglycaemic episodes was higher in non-diabetic patients (34%) than in diabetic subjects (11%, p=0.004). Conclusions: Glycemic variability was calculated during continuous glucose recording in patients with acute stroke and 13 different indices were calculated. No index of glycemic variability was associated with clinical outcome at 3 months, suggesting a shorter-term effect of glycemic variability on early neurological status post stroke. Continuous glucose recording identified several hypoglycaemic episodes in non-diabetic patients with acute stroke that had been underdiagnosed by periodic finger-prick blood glucose measurements, highlighting that glycaemic management in the context of acute stroke should be further optimised. Furthermore, according to subgroup analyses, it was shown that mean glucose in the first 96 h, as measured by continuous glucose recording, was independently associated with favorable functional outcome at 3 months among acute ischemic stroke patients receiving acute recanalization therapies.Εισαγωγή: Η υπεργλυκαιμία μετά από οξύ AEE είναι ένα συχνό φαινόμενο, το οποίο αναφέρεται έως και στο ένα τρίτο των ασθενών με οξύ AEE και επηρεάζει τόσο τους διαβητικούς όσο και τους μη διαβητικούς ασθενείς. Η υπεργλυκαιμία εισαγωγής έχει συσχετιστεί με παθοφυσιολογικά επακόλουθα που μπορεί να οδηγήσουν σε κακή έκβαση σε ασθενείς με AEE, συμπεριλαμβανομένης της υψηλότερης θνητότητας και της δυσμενούς λειτουργικής έκβασης μετά το ΑΕΕ. Σε ασθενείς με ισχαιμικό ΑΕΕ που λαμβάνουν θεραπείες επαναιμάτωσης, οι αυξημένες τιμές γλυκόζης κατά την εισαγωγή έχουν επίσης συσχετιστεί με χαμηλότερα ποσοστά επανακαναλοποίησης και υψηλότερη πιθανότητα συμπτωματικής ενδοκράνιας αιμορραγίας. Ως εκ τούτου, η κατάλληλη διαχείριση της γλυκόζης στην οξεία φάση αναμενόταν να οδηγήσει σε καλύτερα λειτουργικά αποτελέσματα των ασθενών με ΑΕΕ. Ωστόσο, τα αποτελέσματα των τυχαιοποιημένων-ελεγχόμενων κλινικών δοκιμών στο πεδίο δεν κατέδειξαν σημαντική διαφορά στην αποτελεσματικότητα μεταξύ των ασθενών με οξύ ΑΕΕ στους οποίους χορηγήθηκε εντατική θεραπεία με συνεχή ενδοφλέβια ινσουλίνη σε σύγκριση με την καθιερωμένη φροντίδα. Από την άλλη πλευρά, οι ασθενείς που έλαβαν την εντατική θεραπεία εμφάνισαν σημαντικά περισσότερα υπογλυκαιμικά επεισόδια. Η διερεύνηση άλλων επιλογών υπογλυκαιμικής θεραπείας που λαμβάνουν υπόψη τον υπογλυκαιμικό κίνδυνο και τη γλυκαιμική μεταβλητότητα θεωρήθηκε ότι έχει σημαντική αξία. Η γλυκαιμική μεταβλητότητα θεωρείται η τρίτη συνιστώσα της δυσγλυκαιμίας (μαζί με την υπεργλυκαιμία και την υπογλυκαιμία), αλλά η συσχέτισή της με την έκβαση μετά το εγκεφαλικό επεισόδιο παραμένει μόνο εν μέρει διευκρινισμένη. Μέθοδοι: Διενεργήθηκε συστηματική ανασκόπηση της βιβλιογραφίας και αφηγηματική παρουσίαση των μελετών που περιγράφουν τη διαχείριση της γλυκαιμίας στην οξεία φάση του ΑΕΕ, καθώς και των μελετών που διερευνούν τη συσχέτιση γλυκαιμικής μεταβλητότητας και κλινικής έκβασης μετά το ΑΕΕ.Επιπλέον, έγινε προοπτική μελέτη παρακολούθησης 138 ασθενών με οξύ ΑΕΕ στους οποίους εμφυτεύτηκε συσκευή συνεχούς καταγραφής γλυκόζης για έως 96 ώρες. Δεκατρείς δείκτες γλυκαιμικής μεταβλητότητας υπολογίστηκαν από τα δεδομένα συνεχούς καταγραφής γλυκόζης. Καταγράφηκαν τα κλινικά αποτελέσματα κατά τη διάρκεια της νοσηλείας και της περιόδου παρακολούθησης (90 ημέρες). Καταγράφηκαν επίσης τα υπογλυκαιμικά επεισόδια που αποκαλύφθηκαν από συσκευή συνεχούς καταγραφής γλυκόζης, αλλά δεν έγιναν αντιληπτά από τις μετρήσεις με δακτυλική νύξη. Αποτελέσματα: Σύμφωνα με τη συστηματική ανασκόπηση, η διαχείριση της γλυκόζης θα πρέπει να ξεκινά τις πρώτες ώρες από την έναρξη του ΑΕΕ, κατά προτίμηση εντός των πρώτων 12 ωρών. Όσον αφορά τις τιμές γλυκόζης που επιβάλλουν την παρέμβαση και το εύρος στόχου που πρέπει να επιτευχθεί, είναι προτιμότερο να ακολουθούνται τα όρια που προτείνονται από τις διεθνείς συστάσεις, καθώς ο αυστηρότερος γλυκαιμικός έλεγχος δεν συσχετίστηκε με καλύτερη έκβαση, αλλά συνοδεύτηκε από υψηλότερα ποσοστά υπογλυκαιμικών συμβάντων. Προτείνεται, επίσης, η διάρκεια της θεραπείας να διαρκεί περισσότερο από 48 ώρες, καθώς η παρουσία επίμονης υπεργλυκαιμίας και η σχέση της με χειρότερη έκβαση είναι καλά τεκμηριωμένες. Επιπλέον, προτείνεται μεγαλύτερη διάρκεια της υπογλυκαιμικής αγωγής μέχρι τις 72 ώρες σε οργανωμένες μονάδες ΑΕΕ, ενώ το χρονικό πλαίσιο των 120 ωρών φαίνεται επίπονο για το νοσηλευτικό προσωπικό, χωρίς να σχετίζεται με καλύτερη κλινική έκβαση. Ένας νέος δυνητικός θεραπευτικός στόχος είναι η γλυκαιμική μεταβλητότητα, η οποία υπολογίζεται από διαδοχικές μετρήσεις γλυκόζης. Δεδομένα υψηλότερης ποιότητας μπορούν να ληφθούν με την εφαρμογή συνεχούς παρακολούθησης της γλυκόζης σε ασθενείς με ΑΕΕ. Μέχρι τώρα, υπάρχουν περιορισμένες μελέτες που έχουν αξιολογήσει τη συσχέτιση μεταξύ της γλυκαιμικής μεταβλητότητας και της κλινικής έκβασης μετά από ΑΕΕ.Η συσκευή συνεχούς καταγραφής γλυκόζης τοποθετήθηκε με επιτυχία σε συνολικά 138 ασθενείς με οξύ ΑΕΕ (μέση ηλικία 64±10 ετών, 61% άνδρες, διάμεση βαθμολογία NIHSS κατά την εισαγωγή: 9, IQR: 3-14) μετά από διάμεση διάρκεια 29 ωρών (IQR: 22-35) από την έναρξη του ΑΕΕ. Τριάντα-έξι (26%) ασθενείς ήταν διαβητικοί. Η διάμεση διάρκεια της παρακολούθησης ήταν 78 ώρες (IQR: 66-92) και παρείχε συνολικά 115.846 μετρήσεις γλυκόζης για ανάλυση. Κανένας δείκτης γλυκαιμικής μεταβλητότητας δε σχετίστηκε με τα κλινικά αποτελέσματα μετά το ΑΕΕ, όταν μελετήθηκε το σύνολο των ασθενών. Ωστόσο, στην υποομάδα ασθενών με ΙΑΕΕ που έλαβαν οξεία θεραπεία επαναιμάτωσης, η μέση τιμή γλυκόζης, όπως αυτή μετρήθηκε με τη συσκευή συνεχούς μέτρησης γλυκόζης, σχετίστηκε ανεξάρτητα με την πιθανότητα άριστης λειτουργικής έκβασης στις 90 ημέρες. Ασυμπτωματικά υπογλυκαιμικά επεισόδια εντοπίστηκαν σε 46 ασθενείς (33%) κατά τη διάρκεια των συνεχών καταγραφών γλυκόζης – κανένα από αυτά δεν είχε εντοπιστεί με μετρήσεις με δακτυλική νύξη. Η συχνότητα των υπογλυκαιμικών επεισοδίων ήταν υψηλότερος στους μη διαβητικούς ασθενείς (34%) από ό,τι στα διαβητικά άτομα (11%, p=0.004). Συμπεράσματα: Η γλυκαιμική μεταβλητότητα υπολογίστηκε κατά τη διάρκεια της συνεχούς καταγραφής γλυκόζης σε ασθενείς με οξύ ΑΕΕ και περιγράφηκε με 13 διαφορετικούς δείκτες. Κανένας δείκτης γλυκαιμικής μεταβλητότητας δεν συσχετίστηκε με την κλινική έκβαση στους 3 μήνες, γεγονός που υποδεικνύει μια πιο βραχυπρόθεσμη επίδραση της γλυκαιμικής μεταβλητότητας στην πρώιμη νευρολογική κατάσταση μετά το ΑΕΕ. Η συνεχής καταγραφή γλυκόζης εντόπισε αρκετά υπογλυκαιμικά επεισόδια στους μη διαβητικούς ασθενείς με ΑΕΕ, τα οποία είχαν διαφύγει από τις περιοδικές μετρήσεις γλυκόζης αίματος, υπογραμμίζοντας ότι η διαχείριση της γλυκαιμίας στο πλαίσιο του οξέος ΑΕΕ θα πρέπει να βελτιστοποιηθεί περαιτέρω. Επιπλέον, σύμφωνα με τις αναλύσεις σε υποομάδες, αναδείχθηκε ότι η μέση τιμή γλυκόζης κατά τις πρώτες 96 ώρες, όπως αυτή μετρήθηκε με τη μέθοδο της συνεχούς καταγραφής γλυκόζης, σχετίζεται ανεξάρτητα με τη βέλτιστη λειτουργική έκβαση στους 3 μήνες μεταξύ των ασθενών με ΙΑΕΕ που έλαβαν οξείες θεραπείες επανακαναλοποίησης

Stopping &quot;transient ischemic attacks&quot; by antiplatelet withdrawal.

INTRODUCTION: Transient ischemic attack (TIA) is considered to be an important risk factor for the development of ischemic stroke and requires complete etiopathogenic evaluation and prompt initiation of secondary prevention treatment. In addition, an accurate differential diagnosis should be performed in order to exclude other disorders mimicking TIA. METHODS: In this case report, we describe the clinical and neuroimaging evaluation and the differential diagnosis of a patient with suspected crescendo TIAs. RESULTS: A 79-year-old man presented with recurrent episodes of right-sided numbness over the past 7 months, despite different single and dual antiplatelet therapies that were sequentially prescribed for suspected TIAs. Brain MRI revealed cortical superficial siderosis, symmetrical periventricular leukoencephalopathy and enlarged perivascular spaces. Cerebral amyloid angiopathy was considered in the differential diagnosis of the patient. Antiplatelet withdrawal was recommended and led to complete remission of the patient&apos;s transient focal neurological episodes (TFNE) that were initially misdiagnosed as TIAs. DISCUSSION: Cortical superficial siderosis has been implicated as a key neuroimaging feature of cerebral amyloid angiopathy, a diagnosis which can be supported by the additional radiological findings of symmetrical white matter hyperintensities and enlarged perivascular spaces. Antiplatelet treatment in patients with cortical superficial siderosis may increase the frequency and severity of TFNE, while it increases exponentially the risk of intracerebral hemorrhage. The present case highlights that recognition of cortical superficial siderosis is crucial in the management of patients presenting with transient focal neurological symptoms that can be misdiagnosed as recurrent TIAs

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low

Peer reviewe

Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis.

INTRODUCTION There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice. METHODS We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. RESULTS Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56-0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated. CONCLUSIONS Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation

Bilateral non-bifurcating carotid arteries in a patient with recurrent cerebrovascular events.

INTRODUCTION: Among congenital anomalies of the carotid artery circulation, the presence of a non-bifurcating carotid artery is extremely rare. Relevant cases with unilateral non-bifurcating carotid artery have scarcely been described in the literature. After extensive literature review, only one case with asymptomatic bilateral non-bifurcating carotid arteries associated with persistent proatlantal artery was identified. METHODS: We present the case of a 40-year-old man with recurrent cerebrovascular events presenting non-bifurcating carotid arteries bilaterally. RESULTS: A 40-year-old man presented in the emergency department with a transient ischemic attack. Past medical history included prior ischemic stroke of unknown etiology in the distribution of the left middle cerebral artery, untreated hyperlipidemia and tobacco use. Complete work-up in order to identify the underlying mechanism of the patient&apos;s recurrent cerebrovascular events was negative, except for the finding of non-bifurcating carotid arteries bilaterally, associated with an extensive intracranial anastomosing arterial network. Long-term antiplatelet therapy and statins were administered as secondary stroke prevention therapy. DISCUSSION: Previous reports suggest that non-bifurcating carotid arteries may be associated with atherosclerotic plaque formation in symptomatic cases due to shear stress, tortuosity or other local factors. However, in the absence of atherosclerosis, the pathogenic association of bilateral non-bifurcating carotid arteries with cerebrovascular events remains questionable, but may be considered when other stroke etiologies are excluded