By: Dr Michael B. Fawale

1. Stroke Prevention
Dr Michael B. Fawale
Medicine Department, OAU, Ile-Ife
bimbofawale@live.com

2. Stroke Prevention
• Stroke is best treated by prevention!
• Up to 90% of strokes are preventable
• Stroke prevention hinges on risk modification
• Treatment of cardiovascular risk diseases
• Lifestyle modification

3. Stroke Prevention
• Primary prevention of stroke refers to the treatment of individuals
with no previous history of stroke
• Secondary prevention refers to the treatment of individuals who have
already had a stroke or transient ischemic attack (TIA).
• Most primary and secondary stroke prevention recommendations
focus on ischemic stroke, but some apply to hemorrhagic stroke, or to
cerebral venous thrombosis.

4. Secondary Prevention of Stroke

5. Secondary Prevention of Stroke
• Secondary prevention can be summarized by the mnemonic A, B, C,
D, E, as follows:
• A - Antiaggregants (aspirin, clopidogrel, extended-release dipyridamole,
ticlopidine) and anticoagulants (warfarin)
• B - Blood pressure–lowering medications
• C - Cessation of cigarette smoking, cholesterol-lowering medications, carotid
revascularization
• D - Diet
• E - Exercise

6. Transient Ischemic Attack
• The epidemiology essentially mirrors that of stroke
• > 10% of TIAs will develop CI within 90 days
• (4-8% of CI will recur within 90 days)
• 2.6% of TIAs will develop other major CV events within 90
days
• 10-15% of patients have a stroke within 3 months, with half
occurring within 48 hours
• CF: Amaurosis fugax, transient stoke-like syndromes

7. Transient Ischemic Attack
• Controversy exists regarding the need for admission
• Admission to a "rapid evaluation unit" or "observation unit",
dropped the 90-day stroke risk from 10% to 4-5%
• No controversy regarding the need for urgent evaluation, risk
stratification, and initiation of stroke prevention therapy

8. Initial Evaluation
• Level of consciousness and neurologic examination are
usually at the patient's baseline.
• Initial assessment is aimed at excluding conditions that can
mimic a TIA, eg, ICH, hypoglycemia, seizure.
• Laboratory studies- within 24 hours
• RPG, ECG, CT, FBC, coagulation studies, E,U.Cr.
• MRI preferred to CT
• Echo, carotid and vertebral doppler uss

9. Risk Stratification – ABCD2
• Age ≥ 60 years (1)
• Blood pressure 140/ 90 mm Hg on first evaluation (1)
• Clinical symptoms of focal weakness with the spell (2) or
speech impairment without weakness (1)
• Duration ≥ 60 minutes (2) or 10 to 59 minutes (1)
• Diabetes (1).

10. Risk Stratification – ABCD2
• 2-day risk of stroke
• 0% for scores of 0 or 1
• 1.3% for 2 or 3
• 4.1% for 4 or 5
• 8.1% for 6 or 7

11. Decision to Admit
• If presents within 72 hours, hospitalize if:
• ABCD2 score of 3
• ABCD2 score of 0 to 2 and uncertainty that diagnostic workup can be
completed within 2 days as an outpatient
• ABCD2 score of 0 to 2 and other evidence that indicates the patient's event
was caused by focal ischemia
- AHA

12. Management
• Admit for
• Restoration of Vital Signs
• Cardiac monitoring, pulse oximetry
• Intravenous access
• Management of hypertension, hyperglycemia etc
Non-cardioembolic TIA
• Aspirin (50-325 mg/d), combination aspirin/extended-release
dipyridamole, and clopidogrel

13. Management
Cardioembolic TIA
• Atrial fibrillation, Complete heart block, MI, DCM, RHD
• After a TIA, long-term anticoagulation with warfarin (goal INR,
2-3) is typically recommended.
• LMW heparin if warfarin is interrupted
• Aspirin, 325 mg/d
• Mechanical prosthetic valves, warfarin (goal INR 2.5-3.5),
aspirin, 75-100 mg/d
• Bioprosthetic valves, warfarin (goal INR 2-3)

14. Management

15. Management
Carotid Stenosis
• Carotid endarterectomy (CEA) if
• Ipsilateral severe (70% to 99%) for asymptomatic carotid stenosis
• Ipsilateral moderate (50% to 69%) for symptomatic stenosis
• depending on patient-specific factors - age, sex, and comorbidities
(CAS – an alternative)
• Stenosis <50%, no indication for CEA/CAS
• CEA within 2 weeks is reasonable

16. Antiplatelets
• Aspirin
• A 15% relative risk reduction in vascular events (stroke, death, MI) compared
with placebo
• Dose varies from 75mg to 325 mg daily
• Clopidogrel - 75 mg daily
• Had a relative risk reduction of ~ 9% for stroke, death, and MI compared with
aspirin

17. • Ticlopidine – 250 mg twice daily
• Relative risk reduction of ~ 9% for stroke, death, and MI compared with
aspirin
• Side effects (diarrhea, skin rash, and reversible agranulocytosis) limit use
• Dipyridamole – 200mg b.d
• Aspirin + extended-release dipyridamole is more effective than aspirin alone.
Antiplatelets

18. Primary Prevention of Stroke

19. Prevention
Risk modification
• Hypertension
• Antihypertensive therapy reduces stroke risk by about 38%
• Reduction of diastolic BP by 6 mmHg reduces stroke risk by more
than 33%
• Reduction of systolic BP by 3mmHg reduces risk by 8%
• Diabetes
• No demonstrated benefit in stroke reduction with tight glycemic
control
• BP control and statins reduce stroke risk in DM

20. Prevention
• Aspirin - 25% risk reduction
• Carotid endarterectomy: symptomatic atherosclerotic
stenosis of > 70% in the carotid artery
• High Blood Cholesterol
• Stroke risk reduction of 27% to 32% is achieved with statins
• 25% reduction in TIAs
• Smoking Cessation
• Reduces risk by 50% within 1 y; to baseline after 5 years

21. Prevention
• Avoid alcohol drinking
• Recommendation: No drinks at all
• Weight control
• An average weight lossof 5.1 kg reduced systolic BP by 4.4 mmHg
and diastolic BP by 3.6 mmHg
• Exercise
• Recommendation: 30 minutes of moderate-intensity activitydaily

22. Atrial fibrillation (nonvalvular)
• RR = 2.6 – 4.5
• Warfarin vs control: 64% risk reduction
• Aspirin vs placebo: 19% risk reduction
• Warfarin vs aspirin: 39% risk reduction

23. Asymptomatic carotid stenosis
• RR = 2.0
• 50% reduction with endarterectomy
• Aggressive management of other identifiable vascular risk factors

24. Weight Control
• No clinical trial has tested the effects of weight reduction on stroke
risk
• An average weight loss of 5.1 kg reduced systolic BP by 4.4 mmHg and
diastolic BP by 3.6 mmHg
• Therefore, weight reduction is reasonable as a means of reducing stroke risk
• Don’t just advise, set SMART weight management goals

25. Physical activity
• Mechanisms: BP, DM, weight, plasma fibrinogen, platelet
activity & plasma tPA activity and HDL-cholesterol.
• Recommendation (The 2008 Physical Activity Guidelines for
Americans):
• At least 150 minutes per week of moderate intensity
• or 75 minutes per week of vigorous intensity aerobic physical activity
• or an equivalent combination of moderate and vigorous intensity
aerobic activity

26. Sickle Cell Disease
• Screening with TCD starting at age 2 years
• Optimal interval not yet established, more frequently in younger
children and with borderline abnormal TCD velocities
• Transfusion therapy (target reduction of Hb S from a baseline
of >90% to <30%)
• Reduced risk from 10% to 1%
• Hydroxyurea or bone marrow transplantation

27. <15%
Saturated fatty
acids
Polyunsaturated
fatty acids
Monounsaturated
fatty acids
8%-10%
<10%
Recommended Daily Nutrient Content
Carbohydrate
>55%
Protein
15%
Fat
<30%
Cholesterol: <300 mg/d
Fiber: 20-30 g/d

28. Healthy
Eating
Pyramid

29. Diet
• Carbohydrates
• Include at least one starchy food in each main meal
• Use refined carbohydrates sparingly
• Fats
• Low-fat dairy products and low saturated and total fat diets reduce BP and
stroke risk
• Yoruba diet has lower mean cholesterol level (166mg/dl) compared to
that of the African Americans (220mg/dl) (Ogunniyi et al ,2000)

31. Diet
• Proteins
• Red Meat - Use Sparingly
• Fish, Poultry, and Eggs - 0-2 times a day
• Nuts and Legumes - 1- 3 times a day
• Nuts and legumes are an excellent source of protein, fiber, vitamins, and
minerals.
• Examples: Brown beans, soya beans.
• Contain healthy fat, good for the heart.
Milk
• A good source of calcium
• Try to stick to low or no fat milk

32. Fruits and Vegetables
• Increased fruit and vegetable consumption is associated witha
reduced risk of stroke in a dose-response fashion
• For each 1-serving/day increment in fruit and vegetable intake, the
risk of stroke was reduced by 6%
- Nurses’ Health Study & the Health Professionals’ Follow-Up Study
• Vegetables- to be taken in abundance, every meal, every day.
• Fruits (2-3 times a day)

37. Salt
• 75% of the salt we eat is already in food when we buy it
• Avoid foods high in salt
• Fast foods, canned foods, tomato ketchup, mayonnaise, roasted nuts,
smoked meat and fish.
• No added salt at table
• Recommended daily intake of table salt for adults: not more
than 6g a day: around one full teaspoon

38. Conclusion
• Stroke is a disease of major public health importance in Nigeria &
mortality is still very high
• Recognition by patients and care providers that stroke is a medical
emergency will change the current picture
• Stroke is preventable and prevention is the only affordable option for
developing countries
• TIA is not benign

39. Thank You