Clinical Review ABC of arterial and venous disease

Secondary prevention of transient ischaemic attack and stroke

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7240.991 (Published 08 April 2000) Cite this as: BMJ 2000;320:991
  1. Kennedy R Lees,
  2. Philip M W Bath,
  3. A Ross Naylor

    Stroke or transient ischaemic attack is common and likely to be fatal or cause serious disability. A second stroke will not necessarily be of the same type as the initial event, although haemorrhages tend to recur. Patients with previous stroke commonly succumb to other vascular events, in particular myocardial infarction. Effective secondary prevention depends on giving attention to all modifiable risk factors for stroke as well as treating the causes of the initial stroke. Four questions should be answered:

    Risk of recurrence after stroke or transient ischaemic attack

    Stroke
    • 8% a year

    Transient ischaemic attack
    • 8% risk of stroke in first month

    • 5% risk of stroke a year thereafter

    • 5% risk of myocardial infarction a year

    Modifiable risk factors for stroke

    • Hypertension

    • Smoking

    • Diabetes mellitus

    • Diet: high salt and fats, low potassium and vitamins

    • Excess alcohol intake

    • Morbid obesity

    • Low physical exercise

    • Low temperature

    • Cholesterol concentration—at least in patients with coronary disease

    Is it acute cerebrovascular disease?

    The key features of acute cerebrovascular disease are focal neurological deficit, sudden onset, and absence of an alternative explanation. Abrupt onset of a dense hemiparesis before gradual improvement in a conscious patient rarely causes doubt, but conditions which commonly mimic stroke must be considered (see previous article BMJ 2000;320:920-3).

    Is it ischaemic or haemorrhagic stroke?

    Neither clinical history nor examination can reliably distinguish infarction from primary intracerebral haemorrhage. A small bleed can produce transient symptoms, although these rarely resolve within an hour.

    Computed tomograms on days 0 (left) and 8 (right) after left subcortical haemorrhage presenting as a transient ischaemic attack with symptoms lasting 50 minutes. Note the resolution of diagnostic appearances at day 8

    Cerebral imaging is essential, and the choice and timing of the scan is important. Haemorrhage is immediately apparent on computed tomography, but its distinctive appearance becomes indistinguishable from infarction over a few weeks; for major symptoms, a computed tomogram taken within two weeks should still be diagnostic, but a small bleed may be missed after one week. …

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