What is the management and prevention of stroke?

Comprehensive Management and Prevention of Stroke

The most effective approach to stroke management includes rapid diagnosis, immediate treatment with appropriate interventions like thrombolysis when indicated, and comprehensive risk factor modification to prevent recurrence, focusing on blood pressure control, antiplatelet/anticoagulation therapy, lipid management, and lifestyle modifications.

Types and Epidemiology

• Stroke is the fourth leading cause of death in the United States, with approximately 795,000 people experiencing a stroke annually, of which about 610,000 are first-time events 1
• Approximately 85% of strokes are ischemic (caused by blood vessel blockage), while 15% are hemorrhagic (caused by bleeding in the brain) 2
• Major causes of ischemic stroke include small vessel arteriolosclerosis, cardioembolism, and large artery athero-thromboembolism 2
• Hemorrhagic strokes can be deep (basal ganglia, brainstem), cerebellar, or lobar, with deep hemorrhages usually resulting from hypertensive arteriopathy 2

Acute Management of Ischemic Stroke

Thrombolytic Therapy

• Intravenous tissue plasminogen activator (tPA) should be administered to eligible patients within the approved time window, with earlier treatment associated with better outcomes 3
• Treatment with tPA carries risk of intracranial hemorrhage, which increases with higher doses and delayed administration 3, 4
• Patients should be evaluated and treated at specialized stroke centers when possible, as this improves outcomes by approximately 20% 5

General Supportive Care

• Early mobilization and measures to prevent complications (aspiration, malnutrition, pneumonia, deep vein thrombosis, pressure sores) are strongly recommended 1
• Subcutaneous anticoagulants, intermittent external compression stockings, or aspirin should be used to prevent deep vein thrombosis in immobilized patients 1
• Swallowing assessment before oral intake is crucial to prevent aspiration, especially in patients with brain stem infarctions, multiple strokes, large hemispheric lesions, or depressed consciousness 1

Management of Complications

• Brain edema typically peaks 3-5 days after stroke and requires close monitoring, particularly in patients with large infarctions 1
• Pneumonia is a significant cause of death following stroke and requires prompt antibiotic treatment when suspected 1
• Urinary tract infections are common; indwelling catheters should be avoided when possible to reduce infection risk 1

Prevention of Stroke

Primary Prevention

• Hypertension is the most important modifiable risk factor for stroke; blood pressure should be controlled to <120/80 mmHg through medication and lifestyle changes 6
• Statin therapy is recommended for those with atherosclerosis or LDL-C ≥100 mg/dL, targeting at least 50% reduction in LDL-C or a goal of <70 mg/dL 6
• Complete smoking cessation is essential for stroke prevention 1, 6
• Regular physical activity (at least 30 minutes of moderate-intensity exercise daily) is recommended 6
• A Mediterranean diet pattern with reduced salt intake is recommended 6

Secondary Prevention

Antithrombotic Therapy

• For ischemic stroke not related to atrial fibrillation, antiplatelet therapy is recommended 1
• Short-term dual antiplatelet therapy is recommended only in specific cases, including early arriving minor stroke, high-risk TIA, or severe symptomatic intracranial stenosis 1
• For patients with atrial fibrillation, anticoagulation therapy (e.g., rivaroxaban) is recommended if there are no contraindications 1, 7

Management of Specific Etiologies

• For patients with severe carotid stenosis ipsilateral to a non-disabling stroke or TIA, carotid revascularization (endarterectomy or stenting) should be performed relatively early 1
• For patients with severe intracranial stenosis, aggressive medical management of risk factors and short-term dual antiplatelet therapy are preferred over angioplasty and stenting 1

Risk Factor Management

• Intensive management of vascular risk factors is crucial, including diabetes, smoking cessation, lipids, and especially hypertension 1
• Multidisciplinary teams should be involved in risk factor management, with therapy goals tailored to individual patients 1

Lifestyle Modifications

• Regular moderate-intensity aerobic exercise (at least 30 minutes daily) is recommended 6
• Following a Mediterranean diet pattern and reducing salt intake significantly reduces stroke risk 6
• Increasing plant-based food intake and reducing saturated fat, cholesterol, sodium, and calories is recommended 6

Common Pitfalls to Avoid

• Inconsistent medication adherence significantly increases stroke risk, with up to 40% of stroke patients not taking medications as prescribed 6
• Simply providing health information without behavioral interventions is ineffective; structured programs using behavior change theory with ongoing support are necessary 6
• Addressing multiple risk factors simultaneously is more effective than focusing on individual factors 6
• Physical activity is only effective if done consistently; finding sustainable activities is essential 6
• Delayed evaluation and treatment of acute stroke significantly reduces the effectiveness of interventions like tPA 8

Special Considerations

• Stroke in younger patients (<50 years) may have different etiologies, including arterial dissection, vascular malformations, or venous sinus thrombosis 2
• Patients with severe stroke or posterior fossa infarctions require careful observation for early intervention if neurological deterioration occurs 1
• Implementing multiple lifestyle changes simultaneously could lower the risk of a second stroke by up to 80% 6