Stroke prevention

Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90 mmHg and LDL cholesterol under 1 g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3 weeks after a minor ischemic stroke or TIA and for 3 months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (< 6 months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70 years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.Glossary95% CI95% confidence intervalAFatrial fibrillationAHA/ASAAmerican heart association/American stroke associationAVMsarteriovenous malformationsBMIbody mass indexBPblood pressureCAAcerebral amyloid angiopathyCAScarotid angioplasty and stentingCCMcerebral cavernous malformationCEAcarotid endarterectomyECSTEuropean carotid surgery trialESUSEmbolic stroke of undetermined sourceHRhazard ratioICHintracerebral hemorrhageINRinternational normalized ratioLAAlarge artery atherosclerosisLAAOleft atrial appendage occlusionLDL-Clow-density lipoprotein cholesterolMRImagnetic resonance imagingNASCETNorth American symptomatic carotid endarterectomy trialNOACNon-vitamin K antagonists' oral anticoagulantORodds ratioPFOpatent foramen ovaleRCTsrandomized controlled trialsRRrisk reductionSVDsmall vessel diseaseTIAtransient ischemic attackVKAsvitamin K antagonist