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12.11.09 Stroke prevention

Risk factors
  • BLOOD PRESSURE
    • RR x6-7
    • Target 130/80
    • Each 1 mmHg reduction => 3% risk reduction
      • Even if you're normotensive
  • AF
    • Warfarin => 70% risk reduction
  • Cholesterol
    • Only for ischaemic stroke
  • Good diabetes control
    • But usually the effect of this is more apparent for cardiovascular risk
  • Smoking
    • RR x2
    • Again, reduction of CV risk is the bigger effect
  • Exercise
    • 30 mins, 3 times a week
  • Carotid stenosis >70%
  • Diet
  • ARTERIAL thrombophilias
    • NOT e.g. Factor V Leiden, unless there's also a R=>L shunt


Arterial thrombophilias

  • Antiphospholipid syndrome
    • Autoimmune, hypercoagulable state caused by antibodies against cell-membrane phospholipids
      • Anticardiolipin antibodies, anti-β2-glycoprotein 1 antibodies, lupus anticoagulant
  • Anticardiolipin antibodies
    • Found in several diseases including syphilis, antiphospholipid syndrome, livedoid vasculitis, vertebrobasilar insufficiency, Behçet's syndrome, idiopathic spontaneous abortion, and SLE
  • Lupus anticoagulant
    • Most patients with a lupus anticoagulant do not actually have lupus erythematosus
      • But patients with lupus erythematosus are more likely to develop a lupus anticoagulant than the general population
    • The term "anticoagulant" accurately describes its function in vitro, but in vivo, it functions as a coagulant
      • Antibodies interact with platelet membrane phospholipids, increasing adhesion and aggregation of platelets
      • But in vitro, it sequesters the phospholipid activators and so increases aPTT

Carotid endarterectomy
  • Useful within 12 weeks of stroke, if >70% narrowed
    • Otherwise risk outweighs benefit
    • Some benefit for 50-70% narrowing if done within 2 weeks
  • Open repair better than endovascular stenting due to risk of embolisation
    • Even when a sieve is in place
    • Open surgery uses a clamp so less risk
  • Careful of the nerves!

Notes
  • Haemorrhagic stroke => LOOK FOR A SECONDARY CAUSE
  • Lupus has four main types:
    • Systemic (SLE)
    • Discoid
    • Drug-induced
    • Neonatal
  • Rheumatoid factor is an against the Fc portion of IgG
  • Three main ANCA-associated vasculitidies:
    • Churg-Strauss syndrome
    • Microscopic polyangiitis
    • Wegener's granulomatosis
  • Anti-apolipoprotein H (AAHA) antibodies
    • AKA anti-β2 glycoprotein I antibodies
    • Subset of anti-cardiolipin antibodies and lupus anticoagulant
    • Strongly associated with thrombotic forms of lupus
    • Strongly implicated in autoimmune deep vein thrombosis
  • CREST syndrome: Calcinosis, Raynaud's phenomenon, Esophageal dysfunction, Sclerodactyly, Telangiectasias
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