Should antiplatelet agents such as Aspirin be prescribed in CADASIL?
Drugs such as Aspirin reduce the risk of recurrent stroke in people who have already had common stroke. We don’t know whether they have a similar effect in CADASIL. Our policy is usually to recommend Aspirin or a similar antiplatelet drug called Clopidogrel (Plavix) in CADASIL patients who have suffered a stroke, or who are over age forty. However the evidence for this is not strong.
We would advise patients not to take both Aspirin and Clopidogrel because this combination is associated with an increased risk of bleeding into the brain in people with diseases of the small blood vessels in the brain. Similarly, we would advise against taking Warfarin or one of the new oral anticoagulant drugs unless there is a good reason for it (such as atrial fibrillation).
I have CADASIL. Should I take the oral contraceptive pill?
The combined oral contraceptive pill (which contains estrogen and progestogen) is associated with an increased risk of stroke. Even though this is small, we would advise against taking it if you have CADASIL. The mini pill (progestogen only) is associated with a lower risk of stroke and would be a better option if oral contraception is used.
I have CADASIL. Is it safe to take hormone replacement therapy?
HRT for menopausal symptoms is associated with an increased risk of stroke, probably due to a slight increase in blood clotting. For this reason it is better to avoid it in patients who have CADASIL. However, if the menopausal symptoms are very severe, sometimes a decision may need to be made to take it despite the increased risk, but this should be discussed in detail with your doctor.
Should statins be prescribed in CADASIL?
Statins have been shown to reduce the risk of recurrent stroke in people with common stroke. The evidence that they work in stroke caused by disease of the small blood vessels in the brain is much less strong. There is no evidence to show whether they do, or don’t, help in CADASIL. Because of their benefit in common stroke we tend to recommend taking statins in CADASIL if the cholesterol is elevated although the evidence for this is not strong.
Are there any supplements that have been shown to help with CADASIL symptoms such as co-enzyme Q10, omega-3, L-arginine or B vitamins?
There is no evidence that any of these supplements help in CADASIL. It was suggested that L-arginine might improve CADASIL and this could possibly increase the blood flow to the brain in people with CADASIL. However there is no evidence from clinical trials that this improves the outcome.
In people who have very elevated homocysteine levels we sometimes recommend reducing these with B vitamins and folic acid.
What lifestyle changes can help with CADASIL?
Because it has been shown that common cardiovascular risk factors such as smoking and high blood pressure worsen CADASIL we would recommend that a healthy lifestyle is adopted which reduces cardiovascular lifestyle factors. This includes maintaining a normal weight, having a healthy heart friendly diet (details of such a diet can be found on websites such as the British Heart Foundation), not smoking, and avoiding excessive alcohol.
Regular exercise reduces blood pressure and has also been shown to reduce the risk of common stroke. There is increasing evidence that regular exercise also protects the brain from cognitive decline and dementia and therefore we would strongly recommend this.