A Primer on Stroke Prevention Treatment: An Overview Based on AHA/ASA Guidelines

Broderick, Professor Dr. honey and Chair, Department of Neurology UC Neuroscience Institute University of Cincinnati Cincinnati, OH, USA Mark Chan Researcher Ph.D. Chief Neurologist, Jackson Memorial Hospital University of Miami Miller School of Medicine Miami, FL, USA.

George Howard and Virginia J. Howard

䊏 The “big three” risk factors that contribute over half of the population's attributable risk: hypertension, diabetes, and smoking. 䊏 Important risk factors to control regardless of direct stroke risk: dyslipidemia and syndrome metabolic.

Stroke mortality and its disparities

30% and 50% This map shows that specific regions (such as the "buckle" region of the stroke belt along the coastal plain of North Carolina, South Carolina, and Georgia) have a stroke mortality rate well over twice that of other regions. Finally, depending on gender and age group, the magnitude of the Southern excess stroke mortality is between 6% and 21% greater for African Americans than for whites [10].

Stroke risk factors

It is clear that these three risk factors can be called 'the big three' of the first level. The other three “first-line” risk factors – history of heart disease, atrial fibrillation and LVH – are equally (or perhaps even more) important in individual patients with these prevalent conditions [12,13].

Table 1.1 Summary of recommendations from the American Heart Association Guidelines for primary stroke prevention Nonmodifi able

The projected future burden of stroke on the healthcare system

A number of other risk factors discussed in the AHA/ASA Primary Prevention Guideline have been documented in individual studies as potentially related to increased risk of stroke [11]. Although their role in increasing the risk of stroke may be relatively minor, and additional information may be needed to better understand their roles, the treating physician should be aware of each and consider them for treatment.

Soojin Park and Lee H. Schwamm

The patient was transferred to the neuro-intensive care unit, where he was closely monitored overnight. Rather than attempting to transfer the patient to the nearest comprehensive stroke center (40 miles away) before treatment, they contacted the stroke center for a telemedicine-enabled stroke (telestroke) consultation at 11:00 p.m., 2 hours after she was last known. to be good.

Discussion

A model for stroke systems

Defi ning the components of the ideal stroke system

EMS dispatch guidelines should be reorganized to require that acute stroke patients be given the highest priority response. To monitor the quality of acute stroke care nationally, Congress directed the CDC to establish Paul.

Table 2.4 Major elements of a primary stroke center [31]

Conclusion

They are mainly structured around the seven domains identified by the ASA Stroke Systems of Care Task Force. Examples of innovative ways in which stroke care systems are being implemented regionally are provided in Table 2.8.

Gaps in current knowledge

While regional development of stroke systems is essential, efforts at the national level to reduce death and disability from stroke through systems of care are also important. The good news is that hospitals continue to voluntarily improve the quality of stroke care.

Papamitsakis and Robert J. Adams

Primary stroke prevention: a primer

Primordial prevention

The term is increasingly used to refer both to the promotion of physical fitness and healthy behaviors in individuals and to strategies for improving cardiovascular health at the community level [2].

What is the risk of a fi rst stroke?

Multifaceted intensive interventions in patients with DM (including the use of statins, angiotensin receptor blockers [ARB], angiotensin-converting enzyme inhibitors [ACE-I], antiplatelet agents, and behavioral changes) also reduce the risk of stroke. than cardiovascular events. Several studies have found an increased risk for ischemic stroke in patients with elevated total cholesterol.

Table 3.2 Modifi able stroke risk factors, well-documented [4]

Harold P. Adams, Jr

Introduction

Such treatment is complex, with treatment priorities influenced by the interval from the onset of the ischemic symptoms, the severity of the stroke, and the development of medical or neurological complications (Table 4.1). The elements of the subsequent inpatient treatment are determined based on the patient's neurological status and the presence of comorbid diseases.

An integrated approach to treatment of acute ischemic stroke

Much of the management of stroke mimics that of treating patients with acute myocardial ischaemia (Table 4.3). Another important component of the history is the determination of the time of onset of symptoms (taken as the time when the patient was last in his baseline status).

Table 4.3 Similarities and differences in emergency treatment of ischemic stroke and myocardial infarction

Clinical presentations of acute ischemic stroke

Patients have loss of neurological function (neurological disorders) that reflect the area of ​​the brain injury. Patients with basilar artery occlusion may suddenly experience reduced consciousness [25].

Table 4.5 Differential diagnosis of acute ischemic stroke

Evaluation of a patient with ischemic stroke

4.1 (a and b) Axial views of a computed tomographic scan of a patient with a left middle cerebral artery occlusion. MRA may demonstrate severe stenosis or occlusion of the major intracranial or extracranial vasculature [46] (Figure 4.4).

Table 4.7 Components of the National Institutes of Health Stroke Scale

General emergency management

High blood pressure is commonly found and is associated with increased risk of neurological deterioration and poor outcomes [66,67]. A careful lowering of blood pressure in the first hours after a stroke is recommended.

Table 4.11 Treatment of arterial hypertension acute ischemic stroke

Emergency treatment of the acute ischemic stroke itself

Stroke present on awakening (unspecified time) – not treated If previous transient ischemic attack (complete resolution), hr. Signs of active bleeding on examination - not treated Any medication associated with increased risk of bleeding.

Table 4.14 Treatment of patients with acute ischemic stroke with IV tissue-type plasminogen activator – questions to ask Did the stroke begin within the last 3 hours?

General treatment after admission to the hospital

Mechanical endovascular interventions are increasingly used to treat patients with acute ischemic stroke; these may be used in conjunction with thrombolytic medications. Surgical decompression or ventricular drainage is also recommended for the treatment of patients with mass-producing cerebellar infarcts [125-127].

Table 4.16 Components of management hospitalization for acute ischemic stroke

Opeolu Adeoye and Joseph P. Broderick

䊊 Future trials should clarify the role of prothrombin complex concentrates and/or recombinant activated factor VII in warfarin-related ICH. 䊊 Ongoing studies should clarify the role of less invasive stereotactic techniques and clot evacuation by thrombolysis.

Emergency evaluation and diagnosis of intracerebral hemorrhage (ICH)

䊊 Vitamin K and fresh frozen plasma should be administered for rapid correction of coagulopathy. Secondary causes of ICH must be excluded as these may be amenable to intervention, eg, aneurysm clipping for SAH.

Treatment of acute ICH/IVH Medical treatment of ICH

However, a rapid drop in blood pressure in the first 24 hours after symptom onset has also been associated with worse outcomes [33]. In addition, the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage (INTERACT) pilot study was recently completed [43].

Prevention of deep vein thrombosis and pulmonary embolism

In a series of 761 consecutive patients with ICH, early attacks occurred in 4.2% of patients, and 8.1% had attacks within 30 days of onset. ICH-related seizures are often nonconvulsive and are associated with higher NIHSS, midline shift, and a trend toward worse outcomes [62].

ICH related to anticoagulation and fi brinolysis: management of acute ICH

ICH related to fi brinolysis

Surgical treatment of ICH/IVH Craniotomy

• hours
• hours
• hours
• hours

At 3, 6 and 12 months there was no statistical difference in the functional outcomes (using the BI score) between the two groups [124]. In the STICH trial, “early” surgery was compared with initial conservative treatment for 1,033 patients with ICH [ 106 ].

Withdrawal of technological support

It is striking that three of the seven patients with pupillary abnormalities recovered well, as did four of the eight with clots >60 ml.

Prevention of recurrent ICH

The treatment of ruptured aneurysms should be carried out by teams experienced in the two main treatment modalities: microsurgical 'clipping' and endovascular. Unruptured cerebral aneurysms are treated very differently from ruptured lesions, as the natural history is relatively benign; The decision to treat should be carefully weighed against risks, taking into account patient- and aneurysm-specific factors.

Introduction and defi nitions

Epidemiology, risk factors, and genetics

Imaging characteristics Diagnosis of SAH

Additionally, antifibrinolytic therapy to prevent rebleeding may be considered in certain clinical situations, eg, patients with a low risk of vasospasm and/or a beneficial effect of delaying surgery (Class IIb, Level of Evidence B). 4 In some cases, it may be reasonable to reduce fluid administration to maintain a euvolemic state (Class IIb, Level of Evidence B).

Table 6.1 Continued

Management of ruptured aneurysms Initial evaluation

The coils are thrombogenic and cause an acute occlusion of the aneurysm while preserving flow in the surrounding normal vessels. Angiography of the external carotid arteries in anteroposterior (c) and lateral (d) projection clearly shows a dural-based arteriovenous stula with an associated venous aneurysm (double arrows).

Fig. 6.4 CT scan after aneurysmal rupture almost always shows varying amounts of subarachnoid hemorrhage (a–d), although additional intraventricular (c) or intraparenchymal (d) blood is not infrequently seen and often suggests the location of the aneurys

In-hospital care and complications

Delayed hydrocephalus (usually communicating hydrocephalus) can occur at any time in the first 1-4 weeks after SAH; It may resolve spontaneously or require placement of a ventriculoperitoneal shunt (Table 6.1, section 10). Once vasospasm is diagnosed, medical treatment consists of “triple H” therapy: hypertension, hypervolemia and hemodilution (Table 6.1, Chapter 9).

Management of unruptured aneurysms

These cardiac markers do not necessarily indicate myocardial damage and should not delay early surgical intervention for aneurysm treatment [42]. Findings of markedly reduced ejection fraction with wall motion abnormalities inconsistent with the electrocardiographic vascular distribution of ischemia help establish the diagnosis [39, 40].

Management of brain AVMs

Treatment of brain AVMs requires complete angiographic obliteration of the nidus, as partial therapy has not been shown to reduce the risk of future bleeding and may increase it. Complications, including minor and major, and transient and permanent, were recorded depending on the nature of the lesion and the experience of the treating team.

Fig. 6.10 A right medial temporal arteriovenous malformation is seen on this T2-weighted axial (a) and coronal (b)

Future directions

Endovascular embolization is a rapidly developing technology that, although not curative, can reduce arterial flow and AVM size, thus enabling surgery or radiosurgery. Classification of recommendations and level of supporting evidence are defined in Table 7.1, and specific AHA/ASA recommendations are provided after each section.

Hypertension

Therefore, secondary stroke prevention is essential to prevent recurrence of clinical and subclinical stroke and the high mortality and morbidity associated with cerebrovascular diseases. Diuretics have also been studied for stroke prevention: they are superior to placebo in secondary stroke prevention [21], similar to ACE-I in primary prevention [22], and the combination of an ACE-I and a diuretic is superior to to an ACE -I alone [12].

Dyslipidemia

HDL-C levels are inversely associated with coronary events [42], and large cohort studies [43] and case-control studies [44] have confirmed this association, particularly for large-vessel disease-related strokes [45,46]. The combination of a statin and niacin appears to be effective in reducing cardiovascular events and remodeling the arterial wall [51,52].

Diabetes mellitus

Randomized trials have shown that blood pressure reduction in diabetics results in a decrease in vascular outcomes including stroke. The analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial [70] will contribute to knowledge about greater blood pressure reduction in diabetics.

Lifestyle modifi cation

In the North Manhattan Stroke Study, the beneficial effects of moderate drinking and the opposite outcome with heavy drinking were confirmed for different ethnic groups [101,102]. Physical activity levels have remained stable for adults in the United States over the past decade [128], and only about half of all adults engage in frequent, regular, vigorous exercise; this ratio is lower for minorities and the elderly, and youth engagement in physical activity is poor [1].

Carotid atherosclerotic disease

5 In patients with symptomatic severe stenosis (>70%) where the stenosis is difficult to access surgically, medical conditions are present that significantly increase the risk for surgery, or when other specific conditions exist such as radiation-induced stenosis or restenosis after CEA; carotid artery stenting (CAS) is noninferior to endarterectomy and may be considered (Class IIb, Level B). 7 In patients with symptomatic carotid occlusion, extracranial circulation/intracranial circulation bypass surgery is not routinely recommended (Class III, Level A).

Intracranial stenosis

Antithrombotic therapy

1 For patients with ischemic stroke or TIA who have rheumatic mitral valve disease, whether or not it is AF. 1 For patients with ischemic stroke or TIA and MAC not documented as calcific, antiplatelet therapy may be considered (Class IIb, Level C).

Fig. 7.1 Algorithm for secondary stroke prevention.

Pamela Woods Duncan, Danielle Blankenship, and Nicol Korner-Bitensky

Introduction and background

Several evidence-based clinical guidelines have been established for rehabilitation and recovery after stroke [12-19]. There are numerous resources available on the Internet that can guide evidence-based post-acute rehabilitation practices.

Recommendations for post-acute stroke rehabilitation and recovery

The assessment findings and likelihood of outcomes should be shared with the patient and family. Each patient and the primary caregiver should be assigned a contact person from the post-acute rehabilitation team for any follow-up.

Management of the consequences of stroke

Patient and family education should be documented in the medical record to avoid conflicting recommendations from different disciplines. For individuals with urge incontinence, a urinary and bladder training program should be considered.

Patient example, continued: best practice assessments, interventions,

Risk of DVT • The patient should be mobilized as soon as possible (getting out of bed, sitting, standing and walking). The patient and the family should be instructed and made aware of all the safety measures that must be observed with J.

Table 8.2 Standardized assessments

Acknowledgement

He will become involved in community-based physical and social activity programs and return to some leisure activities. The success of J's rehabilitation and recovery programs should be assessed periodically using the Stroke Impact Scale.

Cheryl D. Bushnell

Epidemiology of stroke in women

This is most likely because women live longer and the likelihood of dying from stroke increases with age. In addition, it is important to note that twice as many women die from stroke as from breast cancer (Figure 9.2).

Evaluation of stroke in women

Women may be less likely than men to receive thrombolytic therapy (tissue-type plasminogen activator [tPA]) for acute stroke. Although there is clear variability in whether gender differences exist, these data indicate that women may be less likely to receive tPA than men.

Secondary prevention of stroke in women

The results of the survey showed that women (79%) were less likely to agree to receive tPA than men (86%; P and were less certain about this decision. Women were also more likely to express fear about the risks associated with this treatment and the need for more information about the risks than men.

Risk factors for stroke in women

In contrast, the risk of stroke was increased with HT, regardless of the timing of onset [42]. Hypertension, one of the most common risk factors for stroke, is especially common in women.

Fig. 9.3 The impact of the timing of initiation of estrogen replacement on the timeline of atherosclerosis and endothelial dysfunction [44]

Guidelines for cardiovascular disease prevention in women

Screening for depression in women with cardiovascular disease Framingham risk assessment in the absence of diabetes cardiovascular disease. Women at risk (Table 9.1) should have blood pressure control and LDL therapy in certain women [46].

Fig. 9.5 Algorithm for cardiovascular disease prevention in women [46]. From Mosca L, et al

Gender differences in post-stroke recovery and treatment

In the Canadian Stroke Registry, women were significantly more likely to score lower than men on the SIS-16, which represents the physical function domain of the SIS [14]. In addition, the Michigan State Registry found that women scored lower on the physical domain of the SS-QOL than men [63].

Fig. 9.6 Association between disability measured with the modifi ed Rankin Score (0 = no disability and 4 = moderate to severe disability) and various comorbidities [70]

Descriptive epidemiology Mortality

Disparities in their level of general health and access to health care in the United States continue to exist [1-6]. Additionally, according to the 2003 BRFSS, stroke prevalence was higher in the 10 southeastern states than in the other states surveyed.

Fig. 10.1 Death rates for cerebrovascular diseases by sex and race in the United States from 1950 to 2004 (data obtained from the National Center for Health Statistics [8]).

Risk factors

The disproportionate burden of stroke in young African Americans may have a substantial public health impact based on associated direct (e.g., inpatient care, rehabilitation, follow-up care) and indirect (e.g., long-term disability, lost years of productivity). ) costs of a stroke. and poor nutrition), communication barriers and other factors [36]. In the ARIC study, echocardiographically determined left ventricular mass index (LVMI) was an independent predictor of stroke.

Stroke subtypes Ischemic stroke

The prevalence of other stroke risk factors such as patent foramen ovale, homocysteine ​​level, antiphospholipid antibody syndrome and thrombophilias was similar between blacks and whites [43–46]. According to the BWCYSS, the risk of ischemic stroke and ICH is 2.4 times higher during pregnancy and the first 6 weeks after delivery than for non-pregnant women of the same age and race [47].

Vascular cognitive impairment (VCI) Background

Non-primary analyzes of a number of cardiovascular disease prevention trials, which have administered, for example, blood pressure-lowering drug(s), indicate a fairly consistent signal for the reduction of dementia, including AD and VaD [61,64] . Randomized clinical trials such as the Systolic Hypertension in Europe (Syst-Eur) and the Perindopril Protection against Recurrent Stroke Study (PROGRESS) have found maintenance of cognitive vitality associated with blood pressure-lowering therapy.

Stroke severity and recovery from stroke

Neuropsychiatric symptoms such as agitation, aggression, depression, delusions, hallucinations, and wandering can be common with VCI. Clinicians should familiarize themselves with potential side effects associated with psychopharmacological agents that may be used to treat VCI patients, as some may be associated with the risk of myocardial infarction, stroke, hypertension, and metabolic syndrome.

Clinical trials and barriers to participation

An important part of the research design was careful advance planning to address the needs of the African American community during each phase of the study. Church support was sought, as well as recognition of the study by major black legislative groups [94].

Table 10.3 Key barriers to entry into clinical trials as identifi ed in the African-American Antiplatelet Stroke Prevention Study [90]

Gabrielle A. deVeber

The risk of recurrent stroke in children is maximal in the first days and weeks after index stroke [19]. In pediatric rehabilitation, very few therapists specializing in the field of pediatric stroke are available.

Fig. 11.1 Initial magnetic resonance imaging.

The evolution of coagulation

The prevalence of the FVL mutation among both ischemic stroke patients and controls is approx. 7% [33,34]. The association between intrinsic thromboresistance proteins, antithrombin III, protein C and protein S deficiency and venous thromboembolism is indisputable; however, there is no clear and consistent association with ischemic stroke [39].

Fig. 12.1 Cell-based model of coagulation. Schematic showing the three phases of coagulation: initiation, amplifi cation, and propagation.

Fibrinolytic system proteins

In addition, plasma vWF levels may provide incremental value to clinical risk stratification schemes for stroke and other vascular events among individuals with nonvalvular atrial fibrillation [2,3] . A meta-analysis of 54 studies and 54,547 patients using random effects modeling was undertaken to determine the potential relationship between three common gene mutations causing intermediate phenotypes and arterial thrombosis.

Venous thrombotic disorders

Factor Va Leiden has been shown to be inactivated by APC more slowly than normal factor Va, resulting in increased coagulation [91]. Prothrombin G20210A has also been shown to be a risk factor for cerebral venous thrombosis with a gene-environment effect concentrated in patients using oral contraceptives [81].

Relationship between arterial and venous thrombosis risk

Many patients with antiplatelet factor (PF)4/heparin antibodies remain asymptomatic, suggesting that host-specific factors influence the development of clinical thrombosis in HIT [107]. Patients with nephrotic syndrome (NS), especially membranous nephropathy, have a relatively high incidence of both arterial and venous thrombosis [120].

Table 12.2 Association of hypercoagulable states with arterial disease

Natalia Rost and Jonathan Rosand

Any attempt to apply genetic discoveries to patient decision-making must take into account the stage of the genetic research cycle in which the state of knowledge currently resides. Understanding the fundamental disease mechanism benefits patients through improved diagnostic accuracy, disease management and the development of rational treatments.

The genetic architecture of cerebrovascular disease

As an increasing number of genetic risk factors are identified for each disease, however, this limitation may be reduced. The rest of this chapter focuses on applying current knowledge of genetic risk factors for stroke to bedside decision making.

Case studies

• Young patient with stroke and family history of stroke
• Familial ICH
• Young patient with stroke and no family history
• Late-onset ischemic stroke
• Spontaneous ICH in the elderly

Panel (b), a red-free photograph of the right eye of patient III-2 (aged 20 years), shows marked tortuosity of the medium and small arterioles, particularly in the macula. Genetic counseling and testing are generally not indicated in the absence of strong suspicion of a genetic syndrome.

Fig. 13.1 Magnetic resonance imaging (MRI) characteristics in patients with stroke associated with a known single-gene disorder: (a) diffuse involvement in MELAS; (b) white-matter changes in bilateral external capsules and anterior temporal lobe in cereb

Acknowledgements

Sets of genetic markers are already being evaluated for risk prediction in cardiovascular disease [20], prostate cancer [120] and breast cancer [121]. For now, physicians are advised to continue to focus on rigorous treatment of all modifiable risk factors for stroke and to provide thoughtful, competent genetic counseling before ordering genetic testing on their patients.

Kumar Rajamani and Seemant Chaturvedi

CEA for symptomatic carotid stenosis

In the NASCET method, the distal ICA, where the vessel walls are parallel, is used as a measurement reference. However, a delay in surgery exposes the patient to an excessive risk of recurrent stroke in the intervening period.

Which patients benefi t most from CEA?

The ARR of stroke in the CEA-treated near-occlusion group was 7.9% compared with the medically treated group. Using combined NASCET and ECST datasets, Fox and colleagues identified subsets of patients with near-occlusion; The risk of stroke in the medically treated arm in this group was 15.1% compared to 10.9% in the surgical arm (ARR of 4.2%, P.

CEA for asymptomatic carotid stenosis

Although the patients in the NASCET trial were not randomized prospectively on the basis of plaque ulceration, a post hoc analysis showed that the presence of angiographically determined ulceration significantly increased the risk of stroke in medically treated patients with severe stenosis by up to threefold [32] . A meta-analysis of data from 5,223 patients from the large studies of CEA for asymptomatic carotid stenosis showed that surgery was associated with a reduction in the combined risk of any perioperative or subsequent stroke and perioperative all-cause mortality (relative risk 0.69, 95% CI.

Perioperative drug therapy