(Doctors only)

Ischemic stroke prevention  as mainly secondary prevention for stroke, although many of the measures, especially control of risk factors and lifestyle changes such as not smoking, controlling blood pressure, etc., are also important measures to avoid a first stroke.

Initially, we discuss a tailored diagnostic work-up, then general measures for secondary prevention of ischemic stroke, and finally recommendations for specific conditions that are associated with a high risk of stroke.

Investigations

The goal of the ‘‘stroke work-up’’ is to find the cause of the stroke in order to determine the best treatment options to maximize the chance of preventing another stroke.

A thorough ischemic stroke work-up is not just:  

– CT/MRI/MRA/ECHO/CAROTIDS/TCD/LIPIDS/HBA1C –

There is no ‘‘cookbook’’ work-up for ischemic stroke. It is important to consider the patient’s risk factors and stroke syndrome when determining the extent of the diagnostic evaluation. For instance, a 75-year-old man with longstanding hypertension, diabetes, and hypercholesterolemia and lacunars infarct confirmed on brain imaging may need little additional work-up beyond a carotid ultrasound and EKG.

However, a 40-year-old man with no known risk factors and an acute stroke would require an extensive evaluation. The following is a list of the studies that we consider in most stroke patients to distinguish stroke subtype and tailor our preventive measures. In addition to the following, almost all stroke patients should have a complete blood count, electrolytes, creatinine, blood glucose, INR, PTT, and electrocardiogram.

 Initial acute head CT

To rule out ICH and other causes, to assess for old strokes, to detect early signs of ischemia. MRI of the brain/MRA of the neck and brain (circle of Willis)

To localize the lesion.

To try to understand the mechanism by integrating all MRI and MRA data:

– Small-vessel lacunar infarction

–  Large-artery atherosclerosis

–  Embolism

–  Hemodynamic

–  Venous

To say what’s acute and what’s old using diffusion-weighted sequence.

To understand the tissue physiology (perfusion imaging.

To examine the entire cervical and cerebral vasculature for stenosis (atherosclerosis, dissection, etc.), aneurysm, arteriovenous malformation (AVM).

You can see many unexpected things, including incidental findings.

 Possibly, repeat head CT

 To localize the lesion, if patient is unable to have an MRI.

To evaluate the deteriorating patient:

– To assess mass effect/edema

–  To look for hemorrhagic conversion

– To look for stroke recurrence

 CT angiogram (CTA) of the neck and brain (circle of Willis)

To look for arterial stenosis, dissection, aneurysm (especially if the patient is unable to have an MRI).