Risk of recurrent stroke?
15% in 5yrs
Most in the first 6 months
Higher in carotid artery disease
Disability post stroke
1/3rd remain disabled
1 in 7 require institutional care
Risk factors for stroke
HTN Cardiac disease Smoking High waist to hip ratio Alcohol intake Diabetes Depression
Risk of stroke following TIA?
10% at 1 week
20% at 3 months
What treatment should be initiated immediately post TIA?
Aspirin = Reduces stroke recurrence
Statin and Anti-HTN
CT brain/MRI, carotid imaging and ECG
Antiplatelets post stroke?
Aspirin and clopidorgrel for 21 days post stroke superior to aspirin alone
What about BP control post stroke?
SBP <170
Adequate BP control reduces rates of stroke, MI and vascular events
What about thrombolysis?
Within 4.5hrs of ischaemic stroke
IV altapase
BP must be controlled <185/90
Significant benefit for functional outcomes with NIHSS 5-22
Bleeding risk too high for severe strokes or mild strokes or rapidly recovering strokes or high BP >185/90 or INR >1.7 or previous ICH or surgery in 2/52
Effects of thrombolysis?
Internal carotid artery occlusion = 10-15% recanalization
Proximal middle cerebral artery = 25-50% recanalization
33% have functional improvement
7% have hemorrhage:
- 1% die
- 2% get worse
What about clot retrieval?
Anterior circulation large vessel occlusive disease
Within 6 hrs of stroke onset
Time is brain - must do asap
Can have thrombolysis prior
What about decompressive surgery?
Malignant MCA syndrome
Posterior fossa crainectomy for cerebellar infaract
Reduces deaths but increases number of moderate and severely functionally impaired survivors
What about stroke units?
Important for survival and improved functional outcomes
What about AF and strokes
CHADS2 Vasc score >1 = anticoagulate with Warfarin or NOAC
Must control BP
Anticoagulation for secondary prevention of strokes?
NOACs good evidence
Warfarin
What about watchman devices?
Non-inferior to warfarin for cardiovascular death, stroke and systemic embolization
Anti Platelet agents and stroke
Pick 1 - aspirin or clopidogrel after 21 days
2 = increased risk of bleeds with no additional benefit to stroke prevention
Don’t stop once commenced
What about cholesterol management in the prevention of strokes?
High dose rosuvastatin for LDL >3.4
Reduced ischemic strokes
What about cholesterol management in the secondary prevention of strokes?
LDL >2.6 or total cholesterol >3.6
Prescribe on discharge improves survival and reduces recurrence of strokes
What about carotid endarterectomy?
For stenosis >60% ?
Early operation within 2 weeks = most benefit
Must have life expectancy of 5 yrs +
If operative risk >5% = no benefit
Women = less benefit and more risk
Contralateral stenosis = high risk
What about medical treatment for carotid artery disease
Lipid management
What about chronic renal disease and stroke prediction?
Level of proteinuria an independent risk factor of neurological deterioration, mortality and poor functional outcomes
What about repetitive task training to improve functional ability after stroke?
Improves upper and lower limb function
Interventions for spasticity after a stroke?
Botulinum toxin
Genetic risk factors for stroke?
CADASIL - HTRA1 and NOTCH3 genes
Fabry - GLA gene
MELAS - tRNA leu
HDAC9
ACTA2
