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