Patient handout

Large-Artery Atherosclerotic Stroke (TOAST LAA)

PRODUCTION

1. Your condition

This handout is for large-artery atherosclerotic stroke (toast laa). Your care team identified this based on: cortical / borderzone infarct pattern suggesting laa mechanism (aha/asa 2021 pmid 34024117).

Other reasons your team may use this plan: carotid stenosis ≥50% ipsilateral on cta/mra/duplex (nascet measurement; aha/asa 2021 class i); intracranial atherosclerosis on vessel-wall mri or hi-res cta (sammpris chimowitz nejm 2011 pmid 21507093); complex aortic arch atheroma ≥4 mm or mobile component on tee (amarenco 1994; arch 2014).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
atorvastatin	80 mg PO daily	PO	once daily	SPARCL (Amarenco NEJM 2006 PMID 16899775) — high-dose atorvastatin reduces recurrent stroke ~16%; 2026 ACC/AHA Lipid LDL <55 post-stroke
rosuvastatin	20-40 mg PO daily	PO	once daily	Alternative high-intensity statin (2026 ACC/AHA Lipid)
ezetimibe	10 mg PO daily	PO	once daily	IMPROVE-IT — driving LDL toward <55 target (2026 ACC/AHA Lipid)

Plan: LAA secondary prevention bundle (AHA/ASA 2021): statin + antiplatelet (with SAMMPRIS DAPT for ICAD) + BP + glycemic + smoking cessation ± CEA/CAS

3. When to call your provider

Contact your care team if any of the following happen:

New TIA-spectrum / focal deficit → ED
LDL >55 on max statin → ezetimibe + PCSK9i (2026 ACC/AHA Lipid)
BP >140/90 on 3-drug regimen → resistant HTN workup (cardio.htn.resistant.v1)
Restenosis on carotid duplex → vascular surgery re-evaluation
Recurrent event on DAPT → cilostazol or COMPASS add-on

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Symptomatic carotid stenosis ≥50% ipsilateral on NASCET measurement → CEA/CAS within 14 d (AHA/ASA 2021 Class I)
Symptomatic carotid stenosis 70-99% (near-occlusion) — highest event-rate phenotype; expedite intervention within 48 h-7 d (AHA/ASA 2021 Class I)(life-threatening)
Intracranial atherosclerosis 70-99% (MAD — Mod-Adv Disease) on vessel-wall MRI or hi-res CTA — SAMMPRIS DAPT × 90 d + intensive statin (NOT stenting per SAMMPRIS)
Vertebrobasilar atheroma — posterior circulation LAA phenotype; often underdiagnosed; HINTS central features + posterior infarct on DWI
Complex aortic arch atheroma ≥4 mm or mobile component on TEE — often missed source of LAA stroke (Amarenco NEJM 1994 PMID 8035879)
Recent CABG / vascular endovascular procedure → atheroembolic LAA stroke from manipulation of atheromatous aortic arch (AHA/ASA 2021)

5. Follow-up

Stroke clinic 7-14 d + 90 d + 12 mo: LDL <55, BP <130/80, HbA1c <7%, antithrombotic adherence, smoking cessation, carotid surveillance (AHA/ASA 2021)

6. Sources

Guideline: 2021 AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia + ADA 2026