Caplans Stroke : A Clinical Approach 4th edition

Louis R. Caplan

Stroke
Prevention

When meditating over a

disease, I never think of finding
a remedy for it, but instead a
means of preventing it.
Louis Pasteur

Prevention of stroke is much

more likely to have a major
impact on the health and
welfare of the population
than even the most effective
treatment after stroke has
occurred

Despite efforts, much of the population

is still woefully ignorant about stroke

New Prevention
Strategies
In his 2006 Feinberg lecture,
Sacco outlined a shift in
physician strategy for
preventing cerebrovascular
disease

NEW PREVENTION STRATEGIES

Illnesses and behaviors

known to increase the risk of
vascular disease (for
example, smoking, physical
inactivity, hypertension,
diabetes etc). These are the
customary risk factors
that have long been
discussed.

NEW PREVENTION STRATEGIES

Subclinical brain lesions

(e.g., unexpected infarcts,
white matter
hyperintensities,
microbleeds, etc.)

NEW PREVENTION STRATEGIES

Subclinical vascular disease

(e.g., carotid artery plaques,
arterial intima-media
thickness, etc.)

NEW PREVENTION STRATEGIES

Biomarkers and genetic

findings and conditions
known to relate to vascular
disease (e.g., fibrinogen, Creactive protein (CRP),
homocysteine levels, etc.)

NEW PREVENTION STRATEGIES

A relatively new concept that Sacco also

emphasized in his 2006 Feinberg lecture is

the idea of vascular risk modulators
Doctors and epidemiologists have been
accustomed to analyzing various risks as
binary variables.
Studies have shown, however, that risk
factors are all continuous rather than
categorical (yes or no) variables

Nonmodifiable Demographic
Risk Factors
Parents cannot be selected,
nor can race/ethnicity
and sex.
Time cannot be turned back to reverse the

aging process.
Age, race/ethnicity, sex, and family history
of cardiovascular risk factors and disease
are among the most important risk factors
for stroke.

Framingham Studies
as a person ages, his or her risk of stroke

increases, with incidence rates per 10,000

increasing from 22% 32% 83% in the
age groups 45 55, 55 64, and 65 74
years, respectively.

Framingham Studies
Ischemic stroke in patients younger than 45

years is correlated with more frequent

cardiac-origin embolism and less common
occlusive lesions,
whereas in stroke patients older than 65
years, intrinsic large- and small-artery
diseases are most common, closely
followed by cardiac origin embolism

Framingham Studies
African Americans and Asians have a higher

risk of intracerebral hemorrhage than whites

African Americans, persons of Asian descent,
and women have more intracranial occlusive
disease and less extracranial occlusive
disease than white men
Men have a greater frequency of stroke than
women, but because life expectancy is higher
in women, women often outnumber men in
many stroke studies

Framingham Studies
During the premenopausal years, women

have fewer strokes than men, but incidence

levels off after age 60 years

The Importance of Beginning

Prevention at an Early Age
Finding and modifying risk factors at an

early age is far superior to modification

only after an index cardiac or
cerebrovascular event

Hypertension
After age, hypertension is the single risk

factor that most significantly correlates

with stroke

Hypertension
Hypertension is extremely common

Hypertension
Many individuals with high blood pressure

are unaware that they have it; many who

are aware are untreated or undertreated

Hypertension
Blood pressure reduction is effective along

a range of systolic and diastolic blood

pressures, and at all ages, including the
elderly

Hypertension
Systolic blood pressure is at least as

important and may be more important in

promoting stroke and other manifestations
of cardiovascular disease as diastolic
pressure.

Hypertension
Blood pressure reduction is as (or more)

important in women as it is in men.

Hypertension
Pulse pressure is also very important.

Hypertension
Casual blood pressure measurement in a

doctors office are inadequate to quantify

the severity of hypertension.

Hypertension
Twenty-four-hour blood pressure monitoring

yields more useful information than casual

or even multiple daytime blood pressures

Hypertension
The type of antihypertensive agent is

important

Heart Disease
Cardiac disease is a direct cause of stroke

when the heart is a donor source of emboli

to the brain
Atrial fibrillation is the most common
cardiac source of brain embolism

Cardioembolic Stroke
Mitral or aortic valve disease,
Atrial fibrillation of any cause,
Prosthetic heart valves,
Endocarditis,
Myocardiopathies,
Akinetic myocardial segments, and
Ventricular aneurysms

Obesity, Insulin Resistance,

Metabolic Syndrome, and Diabetes
Doctors, in the past, considered blood

glucose levels in a binary fashionpatients

were either diabetic or not, and some might
be prediabetic

Obesity, Insulin Resistance,

Metabolic Syndrome, and Diabetes
Glucose metabolism is heavily linked to the

secretion and effectiveness of insulin, and

to body fat and inflammation

Obesity, Insulin Resistance,

Metabolic Syndrome, and Diabetes
Adipose tissue releases substances that

relate to body energy, glucose levels, and

insulin effectiveness in controlling glucose
utilization
These substances include nonesterified
fatty acids, cytokines, and adiponectin

Obesity, Insulin Resistance,

Metabolic Syndrome, and Diabetes

Obesity
Obesity is an important component of the

metabolic syndrome, and data now clearly

identifies obesity as a major risk factor for
all forms of cardiovascular disease
including stroke.
There is a major epidemic of weight gain
and obesity in the United States and many
other parts of the world.

Obesity
A strong correlation exists between

abdominal obesity and insulin resistance

Most obese individuals have postprandial
hyperinsulinemia and relatively low insulin
sensitivity

Obesity, Insulin Resistance,

Metabolic Syndrome, and Diabetes
Optimizing body weight and glucose

metabolism are clearly very important

strategies to reduce the risk of stroke

Elevated Blood Lipids

Studies do confirm, however, that elevated

low-density lipoprotein cholesterol and low

high-density lipoprotein cholesterol levels
do increase the risk of stroke

Elevated Blood Lipids

One of the strongest indicators that

cholesterol may have an important role in

extracranial and intracranial atherosclerosis
and ischemic stroke is the effectiveness of
hydroxyl- methyglutarylcoenzyme A
reductase inhibitors (statins) in decreasing
the growth of atherosclerotic plaques in the
carotid arteries and reducing the incidence
of stroke.

Elevated Blood Lipids

Although these drugs may have effects on

plaques and vascular endothelia in addition

to their cholesterol-lowering effects,
reduction of low-density lipoprotein
cholesterol is their predominant action

Smoking
In the Framingham study, smoking was a

signifi cant risk factor for atherothrombotic

brain infarction only in men younger than
65 years

Smoking
Paffenbarger and Williams found that

smoking was one of the most important risk

factors among college students who later
had ischemic strokes

Smoking
The total years of cigarette smoking was

the single, most signifi cant, independent

predictor of the presence of severe
occlusive disease

Alcohol Use
The amount of alcohol that an individual

consumes affects his or her stroke risk

Light-to-moderate regular consumption of
alcohol seems to be inversely related to
carotid artery and systemic atherosclerosis,
yet acute and chronic heavy use of alcohol
increases ischemic stroke risk

Transient Ischemic
Attacks
When properly diagnosed, TIAs are an

indication that occlusive cerebrovascular

disease has already become established
TIAs carry a very substantial risk of
imminent brain infarction and should be
handled emergently.

Hormones and Oral

Contraceptive Use
Women with >6 pregnancies are at a

higher risk for stroke and cerebral infarction

than women who have had fewer
pregnancies
risk of cerebral venous thrombosis is
especially high during the puerperium

Sedentary Lifestyle and Lack

of Exercise
A meta-analysis of 23 studies concluded

that there was strong evidence that

moderate and high levels of physical
activity were associated with reduced risk
of total, ischemic, and hemorrhagic stroke

Geographic Location
Stroke Belts region of high incidence of

stroke and stroke mortality is located within

the southeasternportion of the United
States, with extreme mortality rates in
Georgia and the Carolinas

Systemic
Lesions That Indicate the
Presence
of Vascular Disease and
Vascular Risks
Unexpected Brain Infarcts
White Matter Lesions
Microbleeds
Other Target Organ Vascular Damage

Subclinical Cardio-CervicoCranial-Hematologic Lesions

Cardiac and Aortic
Abnormalities in Cervico-Cranial and

Intracranial Arteries That Supply the

Brain
Hematologic Abnormalities

BIOMARKERS AND GENETIC

FINDINGS AND CONDITIONS
KNOWN TO RELATE TO
VASCULAR DISEASE

Genetic Conditions
Fabrys disease,
Homocystinuria,
Ehlers-Danlos syndrome, and
Pseudoxanthoma elasticum

Primary Prevention
Public education must be improved

Primary Prevention
Stop smoking,
Avoid excessive alcohol intake,
Exercise regularly,
Make time for leisure activities,
Avoid becoming overweight,
Decrease intake of foods high in fat and

cholesterol

Primary Prevention
Periodic check-ups with physicians who

monitor blood pressure, weight, blood

sugar and lipid levels, and who inquire
about habits and health practices are
important

Secondary Prevention
Identification of the mechanism of the

initial stroke is most important

Secondary Prevention
Patients who have lacunar infarcts caused

by penetrating artery disease due to

hypertension and in patients who have
hypertensive ICHs, control of blood
pressure is the most important strategy

Secondary Prevention
Patients with severe carotid artery stenosis,

surgery or angioplasty of the involved

carotid artery may be the best strategy

Secondary Prevention
Patients with nonstenosing plaques, statins,

and an agent that decreases platelet

functions, such as aspirin, clopidogrel, or
combined low-dose aspirin and modifiedrelease dipyridamole, are probably most
effective

Secondary Prevention
Patients who have had brain embolism

caused by atrial fibrillation, anticoagulation

with coumadin represents the best strategy
(unless it was contraindicated)

Things to do
Improved general health measures initiated

by individuals concerned about their bodies

Things to do
Education for patients regarding the

symptoms and significance of

hypertension, excess weight, exercise, and
TIAs. Patients should become educated
consumers who recognize and seek the
most competent care

Things to do
Education for the public about the brain

and symptoms that might indicate stroke

and other brain diseases

Things to do
Education of general physicians. Physicians

should know about the warning signs of

stroke, stroke risk factors, and how to
managepatients with cerebrovascular
disease

Things to do
Education of neurologists, vascular

surgeons, neurosurgeons, and other stroke

specialists. These specialists should know
when and how to manage risk factors, as
well as how to treat the presenting stroke
problem

Things to do
Basic and clinical research. This will surely

advance the present capabilities for

diagnosing and treating stroke patients and
stroke-prone individuals