Eduovisual
Nervous System & Special Senses
Ischemic stroke: secondary prevention and risk factor management
— ~795,000 strokes/year in the US; ~25% are recurrent events
— Highest recurrence risk is in the first 90 days post-index event, peaking in the first 2 weeks
— Secondary prevention reduces recurrent stroke by ~80% when all evidence-based measures are stacked (antithrombotic + statin + BP + lifestyle)
— Any patient with confirmed ischemic stroke or TIA (tissue-based definition: transient symptoms with no infarct on MRI still warrants full workup and prevention)
— Cryptogenic stroke patients pending workup completion — start empiric prevention while etiology is sought
— Patients with high-risk TIA: ABCD² ≥4, crescendo TIA, symptomatic carotid stenosis, or AF
— Step 3 questions emphasize the outpatient follow-up window (clinic visit 1–4 weeks post-discharge), medication reconciliation, and etiology-driven prevention rather than acute tPA/thrombectomy decisions
— Expect vignettes where the patient is now 2 weeks post-stroke and you must choose the right antithrombotic, LDL target, BP goal, or imaging follow-up
— Antithrombotic therapy tailored to etiology (antiplatelet vs anticoagulant)
— High-intensity statin with LDL goal <70 mg/dL
— BP control to <130/80 mm Hg
— Diabetes/glycemic management, smoking cessation, weight, OSA screening
— Etiology-specific interventions (CEA/CAS, PFO closure, LAA occlusion)
— Recurrent stroke despite adherence → reassess for occult AF (extended monitoring), aortic arch atheroma, hypercoagulable state, PFO with shunt, vasculitis, or intracranial atherosclerosis
Board pearl: A "TIA" with a corresponding DWI lesion on MRI is reclassified as an ischemic stroke — this changes documentation, disability, driving, and sometimes insurance coverage of secondary prevention services. Always image the brain with MRI when feasible.
— Exact date, location, and vascular territory of index event (anterior vs posterior circulation, lacunar vs cortical)
— Residual deficits and trajectory: improving, plateaued, or worsening (worsening suggests recurrence, hemorrhagic conversion, or depression mimicking decline)
— Hospital workup completed: MRI, vessel imaging (CTA/MRA neck+head), echo (TTE ± TEE), telemetry duration, lipid panel, A1c
— Palpitations, syncope, fatigue → push for extended cardiac monitoring (30-day event monitor or implantable loop recorder) to capture paroxysmal AF
— Headache, neck pain, recent trauma/chiropractic manipulation → carotid or vertebral artery dissection (changes duration of antithrombotic)
— Migraine with aura, miscarriages, DVT history → antiphospholipid syndrome workup
— Young patient, IV drug use, recent dental work → endocarditis with septic emboli
— Snoring, witnessed apneas, daytime sleepiness, AM headaches → OSA, an under-treated stroke risk factor
— Was the patient on antithrombotics before the stroke? "Breakthrough stroke on aspirin" often prompts switch to clopidogrel or addition of statin intensification, not automatic dual therapy
— Statin intolerance history, prior bleeding events, GI ulcer history, fall risk
— Tobacco (pack-years and current use), alcohol (>2 drinks/day raises stroke risk), stimulant/cocaine use
— Driving status — most states require seizure-free and deficit-stable interval; defer to state DMV rules
— Home support, stairs, ability to manage pillbox — predicts adherence
Step 3 management: When a patient presents to your clinic 2 weeks post-stroke, your first task is medication reconciliation and confirmation that etiologic workup is complete. If TTE was done but no rhythm monitoring beyond inpatient telemetry, order a 30-day ambulatory monitor before labeling the stroke cryptogenic. Missed paroxysmal AF is the single most common reversible cause of recurrent "cryptogenic" stroke.
— BP: Target <130/80 mm Hg for most stroke survivors (SPS3 trial supports this in lacunar stroke). Check orthostatics — overtreatment causing orthostasis worsens cerebral perfusion and falls
— HR and rhythm: Irregular irregular pulse → ECG to confirm AF even if prior telemetry was negative
— BMI and waist circumference: Metabolic syndrome screening drives diabetes and lipid targets
— Document NIHSS or modified Rankin Scale (mRS) at each visit to track recovery and detect subtle recurrence
— Visual fields (homonymous hemianopia limits driving), gait, dysarthria, neglect, and cognition (MoCA — vascular cognitive impairment is common and underdiagnosed)
— Post-stroke depression screening with PHQ-9 — present in ~30%, treatable, and improves rehab outcomes
— Carotid bruit: low sensitivity/specificity but prompts duplex if not yet done
— Murmurs: new murmur post-stroke → endocarditis or valvular source; obtain TTE/TEE and blood cultures
— S3, JVD, edema: HFrEF raises stroke risk and influences anticoagulation decisions
— Bilateral arm BP discrepancy (>15 mm Hg) → subclavian stenosis or aortic disease
— Peripheral pulses, ABI if symptoms of PAD (polyvascular disease changes antiplatelet choice)
— Livedo reticularis, splinter hemorrhages → antiphospholipid syndrome, endocarditis, cholesterol emboli
— Tongue/lip telangiectasias → HHT (paradoxical embolism via pulmonary AVM)
— Timed Up and Go, swallow screen (dysphagia raises aspiration pneumonia risk), pressure ulcer survey in poorly mobile patients
Key distinction: In-clinic BP after stroke can be misleadingly elevated due to "white coat" effect or pain. Confirm hypertension with home BP monitoring or 24-hour ambulatory BP before intensifying therapy in a stroke survivor — aggressive lowering in a patient with critical carotid stenosis or watershed-pattern infarct can precipitate recurrent ischemia.
— Fasting lipid panel: drives statin intensity and LDL goal <70 mg/dL
— HbA1c: identifies new or uncontrolled diabetes; goal individualized (~7% for most)
— CBC, BMP, LFTs: baseline for statin/antithrombotic therapy
— TSH (AF workup, energy/cognition), homocysteine only if young or family history
— In patients <55 or cryptogenic: hypercoagulability panel after anticoagulation washout (lupus anticoagulant, anticardiolipin, β2-glycoprotein, factor V Leiden, prothrombin G20210A, protein C/S, antithrombin)
— 12-lead at every visit; AF, prior MI (silent infarct), LVH (suggests longstanding HTN)
— If AF detected: switch from antiplatelet to anticoagulant — a single AF episode ≥30 sec on monitoring is enough to recommend OAC in stroke survivors
— MRI brain with DWI is the gold standard; defines territory, age of lesion, and silent infarcts
— Multiple territories on MRI → cardioembolic or aortic arch source (not single-vessel atherosclerosis)
— CTA or MRA of head and neck: identifies carotid stenosis, intracranial atherosclerosis, dissection, vasculitis
— Carotid duplex acceptable alternative for extracranial carotid but misses intracranial and vertebral disease
— TTE in all; TEE when cryptogenic or suspicion of PFO, LAA thrombus, aortic atheroma, or endocarditis
— Bubble study for PFO if cryptogenic stroke in patient <60
— Inpatient telemetry (often only 24–72 hr) is insufficient
— Outpatient 30-day event monitor or implantable loop recorder (CRYSTAL-AF) if still cryptogenic — detects paroxysmal AF in up to 30% over 3 years
CCS pearl: On CCS, after an ischemic stroke, your standing orders should include "obtain MRI brain, CTA head and neck, TTE, fasting lipid panel, HbA1c, and ambulatory cardiac monitor" before labeling the case cryptogenic. Forgetting prolonged monitoring is a classic CCS deduction.
— Defined as non-lacunar infarct without >50% proximal artery stenosis, no major cardioembolic source, and no other identified cause
— Advanced studies: TEE (LAA thrombus, aortic arch atheroma >4 mm or with mobile components, PFO with shunt), prolonged rhythm monitoring (loop recorder), hypercoagulable panel
— Bubble study during Valsalva: right-to-left shunt within 3 cardiac cycles = intracardiac shunt (PFO/ASD); delayed = pulmonary AVM
— RoPE score estimates probability the PFO is causative — higher score (younger, no traditional risk factors, cortical infarct) favors PFO closure
— Closure indicated in patients <60 with cryptogenic stroke and high-risk PFO features (atrial septal aneurysm, large shunt)
— Young patient, multiple territories, headache, systemic features: ESR, CRP, ANA, ANCA, RF, complement, HIV, RPR, hepatitis serologies
— Vessel wall MRI distinguishes vasculitis (concentric enhancement) from atherosclerosis (eccentric)
— Conventional angiography for primary CNS angiitis if non-invasive imaging suggests it; brain/leptomeningeal biopsy is gold standard
— Acute thrombosis and heparin alter protein C/S and antithrombin levels; LMWH and warfarin distort results
— Repeat antiphospholipid antibody testing at 12 weeks to confirm persistence before diagnosing APS
— CADASIL (NOTCH3 mutation): young patient, migraines, white matter disease, family history
— Fabry disease: cornea verticillata, renal disease, neuropathy — α-galactosidase A activity
— CT or MR aorta for aortic dissection extending to carotids, or arch atheroma in elderly cryptogenic patients
Board pearl: A patient <55 with cryptogenic stroke, livedo reticularis, prior miscarriages, and prolonged aPTT → antiphospholipid syndrome. Treat with warfarin (INR 2–3), not DOACs — the TRAPS trial showed rivaroxaban inferior to warfarin in triple-positive APS.
— Large-artery atherosclerosis (carotid, vertebrobasilar, intracranial): antiplatelet + high-intensity statin + BP control + revascularization if criteria met
— Cardioembolism (AF, LV thrombus, mechanical valve, endocarditis): anticoagulation, not antiplatelet
— Small-vessel (lacunar): antiplatelet + aggressive BP control (<130/80) + statin
— Other determined (dissection, hypercoagulable, vasculitis): cause-specific
— Cryptogenic/ESUS: antiplatelet + standard risk factor management; DOACs not superior to aspirin (NAVIGATE-ESUS, RE-SPECT ESUS were negative)
— ABCD² score for TIA: ≥4 = high short-term stroke risk → hospitalize or expedited workup
— CHA₂DS₂-VASc: stroke itself = 2 points; any stroke survivor with AF qualifies for OAC
— HAS-BLED: informs bleeding risk discussion, not a reason to withhold OAC
— ESSEN score and SPI-II estimate recurrent stroke risk
— Confirm antithrombotic matches etiology (most common error: AF patient discharged on aspirin only)
— Statin: atorvastatin 40–80 mg or rosuvastatin 20–40 mg regardless of baseline LDL
— BP medication: thiazide + ACEi/ARB combination (PROGRESS trial)
— Glycemic and lifestyle counseling
— 70–99% stenosis ipsilateral to event: CEA within 2 weeks offers maximum benefit (NNT ~6)
— 50–69%: CEA benefit modest, individualize
— <50%: medical therapy only
Step 3 management: When you see "patient with ischemic stroke, ipsilateral 80% ICA stenosis, now 5 days post-event" — the answer is carotid endarterectomy within 14 days of symptom onset, not delayed CEA, not CAS (unless surgically high-risk anatomy or age <70). Delaying CEA beyond 2 weeks loses most of the benefit.
— Aspirin 81 mg daily OR clopidogrel 75 mg daily OR aspirin-dipyridamole — all acceptable monotherapy
— Short-term DAPT (aspirin + clopidogrel) for 21–90 days after minor stroke (NIHSS ≤3) or high-risk TIA (ABCD² ≥4): CHANCE and POINT trials showed reduced recurrence; THEN step down to monotherapy — long-term DAPT increases bleeding without added benefit
— For intracranial atherosclerotic stenosis 70–99%: DAPT for 90 days, then monotherapy (SAMMPRIS)
— Ticagrelor + aspirin (THALES) is an alternative DAPT regimen
— Non-valvular AF: DOAC preferred over warfarin (apixaban, rivaroxaban, dabigatran, edoxaban) — lower ICH risk
— Mechanical valve or moderate-severe mitral stenosis: warfarin only (INR 2.5–3.5 for mechanical mitral, 2–3 for aortic)
— Timing of OAC initiation after cardioembolic stroke — "1-3-6-12 rule": TIA day 1, small stroke day 3, moderate day 6, large stroke day 12
— High-intensity statin for all atherosclerotic stroke: atorvastatin 40–80 or rosuvastatin 20–40
— LDL goal <70 mg/dL (TST trial); add ezetimibe, then PCSK9 inhibitor if not at goal
— Statin started even if baseline LDL is "normal" — it's the event, not the number
— First-line: thiazide (chlorthalidone preferred), ACEi/ARB, or combination
— Avoid abrupt lowering in acute period; goal <130/80 long-term
— Beta-blockers not first-line for stroke prevention unless other indication (CAD, HFrEF)
— Pioglitazone reduced recurrent stroke in insulin-resistant patients (IRIS trial) — watch for HF, weight gain, fractures
— GLP-1 agonists (semaglutide, dulaglutide) reduce stroke in T2DM
— SGLT2 inhibitors mainly cardiorenal benefit
Board pearl: "Stroke despite aspirin" is not an automatic indication for adding clopidogrel long-term. Reassess etiology, adherence, and risk factors. Long-term DAPT (>90 days) increases bleeding without reducing recurrent stroke in most patients (MATCH, SPS3).
— Indication: symptomatic carotid stenosis 70–99% (clear benefit) or 50–69% (modest benefit, favor men, recent symptoms, hemispheric over retinal events)
— Timing: within 2 weeks of index TIA/minor stroke for maximum benefit; benefit diminishes sharply after
— Surgeon perioperative stroke/death rate must be <6% for the procedure to be net beneficial
— Asymptomatic stenosis 70–99%: CEA benefit is modest in modern medical era — individualize
— Alternative to CEA in: surgically inaccessible lesions, prior neck radiation/surgery, contralateral CEA, severe cardiac/pulmonary comorbidity
— Age <70 generally favors CAS equivalence; age >70 favors CEA (higher periprocedural stroke with CAS in elderly — CREST trial)
— Requires DAPT for ≥30 days post-stent, then aspirin lifelong
— SAMMPRIS: aggressive medical therapy (DAPT 90 days + statin + BP control) superior to stenting
— Stenting reserved for failure of medical therapy in selected centers
— Indication: cryptogenic stroke in patient age 18–60 with high-risk PFO (large shunt or atrial septal aneurysm) after thorough exclusion of other causes
— Trials: CLOSE, REDUCE, RESPECT long-term — closure superior to medical therapy in selected patients
— Risk: new-onset AF (3–5%, usually transient)
— For AF patients with absolute contraindication to long-term OAC (recurrent major bleeding)
— Requires short-term anticoagulation post-implant
— Generally medical management; stenting reserved for recurrent symptoms on optimal therapy
Step 3 management: Cryptogenic stroke in a 45-year-old with PFO and atrial septal aneurysm → refer for percutaneous PFO closure after confirming no AF on prolonged monitoring and no other identifiable cause. Continue antiplatelet therapy post-closure. PFO closure in patients >60 has not shown clear benefit.
— Stroke risk and bleeding risk both rise — net benefit of antithrombotics usually still favorable, but tailor doses
— Apixaban 2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5
— Avoid dabigatran 150 mg BID in elderly with renal impairment — use 110 mg BID (where available) or alternative
— BP target: <130/80 still appropriate per SPRINT-MIND and recent stroke guidelines, but monitor orthostatics and falls
— Statin benefit persists in elderly — do not stop statin solely for age; consider moderate-intensity if frailty
— CrCl <15 or dialysis: DOACs generally avoided; warfarin is standard for AF, though benefit/risk in dialysis is controversial
— CrCl 15–30: apixaban or reduced-dose rivaroxaban (15 mg) acceptable
— Avoid dabigatran if CrCl <30 (renally cleared, 80%)
— Recheck renal function at least every 6 months on DOAC; more often if AKI risk
— Child-Pugh C: avoid all DOACs; warfarin with caution
— Child-Pugh B: avoid rivaroxaban; apixaban with caution
— Statins: avoid in active liver disease; mild transaminase elevation is not a contraindication
— Use Beers criteria — avoid anticholinergics, long-acting benzodiazepines, NSAIDs (NSAIDs + antithrombotic = high GI bleed risk)
— Falls are not a contraindication to anticoagulation — a patient must fall ~300 times per year for fall-related ICH to outweigh AF stroke prevention
— Vascular cognitive impairment present in ~30% of stroke survivors
— Affects medication adherence — simplify regimens, use pillboxes, involve caregivers
— Capacity assessment before signing complex consent
Board pearl: In an 82-year-old with AF post-stroke, do not withhold anticoagulation due to "age and fall risk." Use apixaban 5 mg BID (or 2.5 mg if meets criteria) — it has the most favorable bleeding profile in elderly per ARISTOTLE.
— Risk highest in third trimester and 6 weeks postpartum (hypercoagulability, preeclampsia/eclampsia, PRES, RCVS, peripartum cardiomyopathy, cerebral venous thrombosis)
— Workup: MRI/MRV brain (safe in pregnancy without gadolinium), echo, hypercoagulable panel after delivery
— Aspirin 81 mg is safe throughout pregnancy and recommended for women with prior stroke
— Avoid warfarin in pregnancy (teratogenic weeks 6–12, fetal hemorrhage later) — use LMWH
— DOACs not recommended in pregnancy or breastfeeding
— Postpartum: resume usual regimen; LMWH compatible with breastfeeding; warfarin compatible
— Estrogen-containing contraceptives contraindicated after stroke → switch to progestin-only, IUD, or barrier
— Hormone replacement therapy: avoid in stroke survivors
— Migraine with aura + smoking + OCP markedly raises stroke risk — counsel and switch contraception
— Differential: dissection, PFO, hypercoagulable state, vasculitis, illicit drug use (cocaine, methamphetamine), Fabry, MELAS, CADASIL, sickle cell
— Sickle cell: transcranial Doppler screening in children; chronic transfusion if elevated velocity; hydroxyurea
— Black, Hispanic, and Indigenous patients have higher stroke incidence, worse risk factor control, and less access to thrombectomy and prevention services
— Step 3 frequently tests recognition of disparities and equitable care strategies (community health workers, language-concordant care)
— Rare; consider congenital heart disease, sickle cell, moyamoya, prothrombotic states, vasculopathy post-varicella
— Acute management at pediatric stroke center; long-term aspirin or anticoagulation depending on etiology
Key distinction: Postpartum sudden severe headache with focal deficit → consider RCVS (reversible cerebral vasoconstriction syndrome) and cerebral venous sinus thrombosis in addition to ischemic stroke. CVST treatment is anticoagulation even in the presence of hemorrhagic infarction.
— Highest in first 90 days; most modifiable factor is etiology-matched antithrombotic
— Recurrent stroke in different vascular territory suggests cardioembolic source — re-evaluate
— Risk factors: large infarct, cardioembolic source, early anticoagulation, uncontrolled HTN
— "1-3-6-12 rule" guides safe OAC initiation timing
— Symptomatic ICH on antithrombotic: hold therapy, reverse if indicated (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors, 4F-PCC for warfarin)
— Affects 30–50%; screen with PHQ-9 at every visit
— SSRIs first-line; sertraline or citalopram preferred (avoid those with QT or bleeding interactions)
— Vascular cognitive impairment — manage vascular risk factors aggressively; cholinesterase inhibitors have modest effect
— Early seizures (<7 days) usually do not require chronic AEDs
— Late seizures (>7 days) imply gliotic focus → treat as epilepsy; levetiracetam preferred (minimal interactions with antithrombotics)
— Screen with bedside swallow before any PO; SLP evaluation if abnormal
— Modified diets, PEG if persistent
— Mobility loss increases VTE risk; prophylactic LMWH during hospitalization, IPC if hemorrhagic conversion concern
— Early PT/OT; botulinum toxin for focal spasticity
— Standard inpatient and rehab prevention bundles
— Statin myopathy (CK), DOAC GI bleeding, warfarin labile INR, ACEi cough/hyperkalemia/AKI
CCS pearl: On CCS, after a moderate-sized cardioembolic stroke, do not start anticoagulation on day 1. Order DVT prophylaxis with LMWH or IPC, repeat head CT at 24–48 hours, and initiate full-dose anticoagulation around day 6. Starting OAC too early triggers hemorrhagic transformation deductions.
— Any new focal neurologic deficit in a stroke survivor → ED for stroke alert (recurrent stroke, hemorrhagic transformation, or seizure)
— TIA with ABCD² ≥4, crescendo TIA, or symptomatic carotid stenosis → admit for expedited workup and CEA evaluation
— New AF with hemodynamic instability → ED
— Large hemispheric infarct (malignant MCA): NIHSS >15, age <60 → consider decompressive hemicraniectomy within 48 hours
— Cerebellar infarct >3 cm: risk of brainstem compression and obstructive hydrocephalus → neurosurgery consult, possible suboccipital craniectomy/EVD
— Basilar artery occlusion: emergent thrombectomy regardless of NIHSS
— Hemorrhagic conversion with mass effect: ICU + neurosurgery
— Airway compromise from bulbar dysfunction: intubation
— Vascular neurology: all recurrent strokes, cryptogenic cases, young patients, dissection
— Vascular surgery: symptomatic carotid stenosis for CEA timing
— Interventional cardiology: PFO closure, LAA occlusion
— Hematology: confirmed APS, inherited thrombophilia, recurrent stroke despite OAC
— Cardiology/EP: AF management, loop recorder
— PM&R/rehab: all moderate-to-severe deficits at discharge
— Inpatient rehab vs SNF vs home with outpatient therapy: based on tolerance of 3 hours/day therapy, support, and rehab potential
— Functional Independence Measure and PT/OT evaluations drive placement
— 30-day readmission rate after stroke ~13%
— Mandatory: medication reconciliation, follow-up appointment within 7–14 days, BP cuff at home, clear teach-back on warning signs (BE-FAST)
Step 3 management: A stroke survivor calls 3 days post-discharge with a new arm weakness lasting 20 minutes that resolved. Send to ED, not clinic — this is a TIA, warning of imminent recurrence, and requires inpatient or rapid-access TIA clinic workup within 24 hours.
— Carotid, vertebral, intracranial stenosis
— Cortical or border-zone (watershed) infarcts
— Bruit, prior CAD/PAD, classic risk factors
— Prevention: antiplatelet + high-intensity statin + revascularization if indicated
— AF, LV thrombus post-MI, mechanical valve, endocarditis, dilated cardiomyopathy, intracardiac tumor (myxoma), PFO
— Multiple vascular territories, cortical infarcts, hemorrhagic transformation common
— Prevention: anticoagulation
— Penetrating artery occlusion: lipohyalinosis, microatheroma
— Classic lacunar syndromes: pure motor hemiparesis, pure sensory, ataxic hemiparesis, dysarthria-clumsy hand, sensorimotor
— Strongly tied to hypertension and diabetes
— Prevention: antiplatelet monotherapy + aggressive BP control (SPS3 showed harm with DAPT long-term)
— Young patient, neck pain, headache, Horner syndrome (carotid) or vertigo (vertebral); often post-trauma or spontaneous
— Imaging: CTA/MRA showing flame-shaped occlusion, intimal flap, or intramural hematoma
— Treatment: antiplatelet OR anticoagulation for 3–6 months (CADISS trial — equivalent), then antiplatelet long-term
— Moyamoya: progressive ICA stenosis with collateral "puff of smoke"; bypass surgery
— Fibromuscular dysplasia: "string of beads" on angiography; antiplatelet
— Primary CNS vasculitis: requires brain biopsy; immunosuppression
— Reversible cerebral vasoconstriction syndrome (RCVS): thunderclap headache, vasoconstriction resolves in 1–3 months; calcium channel blockers, avoid steroids
— APS, factor V Leiden, prothrombin G20210A, protein C/S, antithrombin deficiency, malignancy-associated (Trousseau)
Key distinction: A pure motor hemiparesis with internal capsule lacune on MRI in a hypertensive diabetic = lacunar stroke. Treatment is antiplatelet monotherapy + BP <130/80 + statin — NOT dual antiplatelet long-term, which increased bleeding without benefit in SPS3.
— Distinguished by CT/MRI; risk factors overlap with ischemic stroke
— Prevention pivots: avoid antithrombotics initially; control BP aggressively (<130/80); statins generally continued
— Lobar hemorrhage in elderly → cerebral amyloid angiopathy (MRI GRE/SWI shows microbleeds)
— Elderly, falls, anticoagulants; fluctuating mental status, headache
— Can mimic recurrent stroke — always image before assuming recurrence
— Post-ictal focal weakness lasting minutes to hours
— EEG and history of seizure activity differentiate
— Gradual march of symptoms, positive phenomena (scintillations), headache follow
— Stroke deficits typically negative and sudden
— Always check glucose in any new focal deficit — classic mimic
— Inconsistent exam, give-way weakness, Hoover sign positive
— Diagnosis of exclusion; imaging negative
— Unmasks old strokes (recrudescence); symptoms resolve with treating underlying cause
— Younger patient, gradual onset, MRI shows white matter lesions with characteristic distribution
— Subacute onset, MRI with contrast distinguishes
— Severe HTN, eclampsia, immunosuppressants; posterior white matter edema, often reversible
— Confusion, ophthalmoplegia, ataxia — give IV thiamine before glucose in any malnourished/alcoholic patient
— Peripheral vertigo (BPPV, vestibular neuritis) common; HINTS exam differentiates from posterior stroke
Board pearl: In a stroke survivor on warfarin presenting with new confusion or hemiparesis, always get a non-contrast head CT first — anticoagulation-related ICH and subdural hematoma are more common in this population than recurrent ischemic stroke. Do not give antithrombotics empirically.
— Non-cardioembolic: aspirin 81 mg, clopidogrel 75 mg, or aspirin-dipyridamole (single agent long-term)
— Minor stroke/high-risk TIA: DAPT × 21–90 days, then monotherapy
— Cardioembolic AF: DOAC (apixaban 5 mg BID preferred for most)
— Mechanical valve/severe MS: warfarin
— Dissection: antiplatelet or anticoagulation × 3–6 months
— High-intensity (atorvastatin 40–80, rosuvastatin 20–40)
— LDL goal <70; add ezetimibe, then PCSK9 inhibitor
— Goal <130/80
— Thiazide (chlorthalidone) + ACEi/ARB combination ideal
— Add CCB or beta-blocker as needed
— A1c ~7% (individualized)
— Metformin first-line; add GLP-1 agonist (semaglutide) or pioglitazone for stroke risk reduction in appropriate patients
— Smoking cessation: varenicline or combination NRT + counseling; single highest-yield modifiable factor
— Alcohol ≤2 drinks/day (men), ≤1 (women)
— Mediterranean or DASH diet
— 150 min/week moderate aerobic exercise once medically cleared
— BMI <25 if achievable
— OSA screening (STOP-BANG); CPAP if confirmed
— Annual influenza, pneumococcal per age, COVID, RSV per guidelines, zoster
— PPI only if GI bleeding risk (NSAIDs, age >65, prior ulcer) — not routine
— Avoid NSAIDs whenever possible
Step 3 management: The "perfect" discharge regimen for an AF-related stroke in a 68-year-old: apixaban 5 mg BID + atorvastatin 80 mg + lisinopril 10 mg + chlorthalidone 12.5 mg + smoking cessation + Mediterranean diet + cardiology follow-up + neurology follow-up in 2–4 weeks + home BP monitor. Missing any one is a likely deduction.
— First post-discharge visit: 7–14 days (primary care or stroke clinic) — medication reconciliation, BP review, depression screen
— Neurology follow-up: 4–6 weeks
— Subsequent visits at 3, 6, 12 months, then annually if stable
— BP (home log preferred); orthostatics if symptomatic
— Medication adherence and side effects (statin myalgia, ACEi cough/K, DOAC bleeding)
— Functional status (mRS, NIHSS), cognition (MoCA at 3–6 months), depression (PHQ-9)
— Adherence to lifestyle measures
— Lipid panel: 4–12 weeks after starting/changing statin, then annually
— HbA1c: every 3 months until at goal, then every 6 months
— Renal function and electrolytes: 2 weeks after ACEi/diuretic start; every 6 months on DOAC; more often if CKD
— LFTs and CK: only if symptomatic on statin
— INR: weekly until stable on warfarin, then every 4 weeks
— CBC: annually on antithrombotics
— Inpatient rehab → outpatient PT/OT/SLP → home exercises
— Constraint-induced movement therapy for upper limb
— Aphasia therapy ongoing
— Vocational rehab if working-age
— Defer to state law; typically requires deficit stability, no seizures, neurologist clearance, and on-road testing if homonymous hemianopia or neglect
— Generally resume when able to climb 2 flights without symptoms; counsel that sexual activity is safe for most
— BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) — patient and family
— Stroke support groups, caregiver burnout assessment
Board pearl: A patient with homonymous hemianopia from occipital stroke must not drive until formal visual field testing and on-road assessment. Failure to counsel and document creates liability and is a Step 3 patient safety theme.
— Stroke can impair decision-making capacity (aphasia, neglect, executive dysfunction)
— Aphasia ≠ incapacity — use yes/no questions, communication boards, SLP assistance
— Document capacity assessment for each high-stakes decision (CEA, anticoagulation in fall risk, PFO closure)
— If incapacitated: surrogate per state hierarchy (spouse → adult child → parent → sibling)
— Advance directives, POLST, healthcare proxy — revisit after major stroke
— Most US states do not mandate physician reporting of stroke, but ~6 (CA, DE, NV, NJ, OR, PA) require it
— Always document the discussion and advice not to drive
— Failure to counsel is the most common liability pitfall
— Large strokes with poor prognosis: early palliative care consult, discussion of DNR/DNI, tube feeding, hemicraniectomy
— Avoid premature withdrawal of care in first 24–72 hours — "self-fulfilling prophecy"
— 30-day readmission ~13%; medication errors common
— Required elements: medication reconciliation, follow-up appointment scheduled before discharge, teach-back, written warning signs (BE-FAST), patient portal access
— Discharge summary to PCP within 48 hours
— Black and Hispanic patients receive fewer prevention services and revascularization procedures
— Step 3 may test recognition and mitigation (community health workers, language services, transportation vouchers)
— Black-box: never combine DOAC with NSAIDs without weighing GI bleed risk
— Reversal agents: idarucizumab (dabigatran), andexanet alfa (factor Xa), 4F-PCC, vitamin K + FFP for warfarin
— Suspected elder abuse in stroke survivor (medication withholding, neglect) → adult protective services
— Endocarditis from IV drug use: counsel and offer MAT (buprenorphine, methadone)
Step 3 management: A stroke survivor with new homonymous hemianopia insists on driving home. You must: clearly counsel against driving, document the discussion, arrange alternative transport, notify family per patient permission, and in mandatory-reporting states notify DMV. Allowing the patient to drive creates negligence liability.
— AF → DOAC (apixaban preferred)
— Mechanical valve / severe MS → warfarin only
— APS triple-positive → warfarin (INR 2–3)
— Large-artery atherosclerosis → antiplatelet + statin + BP
— Lacunar → antiplatelet monotherapy (no long-term DAPT)
— Cryptogenic/ESUS → antiplatelet (DOACs failed in NAVIGATE-ESUS, RE-SPECT ESUS)
— Dissection → antiplatelet or anticoagulation × 3–6 months (CADISS — equivalent)
— DAPT after minor stroke/TIA: 21–90 days, then step down
— CEA after symptomatic stenosis: within 14 days
— OAC after cardioembolic stroke: 1-3-6-12 rule (TIA→1d, small→3d, moderate→6d, large→12d)
— APL antibody confirmation: repeat at 12 weeks
— BP <130/80
— LDL <70
— A1c ~7% individualized
— INR mechanical aortic 2–3, mitral 2.5–3.5
— CHANCE/POINT: DAPT × 21–90 days post-minor stroke
— SAMMPRIS: medical > stenting for intracranial atherosclerosis
— SPS3: no long-term DAPT for lacunar stroke
— PROGRESS: ACEi + thiazide reduces recurrent stroke
— SPARCL: high-intensity statin reduces recurrent stroke
— IRIS: pioglitazone in insulin-resistant non-diabetics
— NAVIGATE-ESUS/RE-SPECT ESUS: DOAC not superior to aspirin in ESUS
— CRYSTAL-AF: loop recorder finds occult AF
— CLOSE/REDUCE/RESPECT: PFO closure in <60 with cryptogenic stroke
— TST: LDL <70 superior to <100
— Lateral medullary (Wallenberg): vertigo, ipsilateral Horner, ipsilateral face/contralateral body sensory loss
— Weber: ipsilateral CN III + contralateral hemiparesis (midbrain)
— Lacunar pure motor: posterior limb internal capsule
— Locked-in: ventral pons (basilar)
Board pearl: Pioglitazone reduces stroke recurrence in insulin-resistant non-diabetics (IRIS trial) — a frequently missed therapy. Watch for HF exacerbation, weight gain, and bone fractures; avoid in HF or osteoporosis.
— Vignette: 72-year-old with AF discharged on aspirin presents with new stroke
— Answer: switch to DOAC (apixaban); aspirin is inadequate for AF stroke prevention
— Vignette: cryptogenic stroke after 48-hour inpatient telemetry; what next?
— Answer: outpatient 30-day event monitor or implantable loop recorder
— Vignette: stroke with ipsilateral 80% ICA stenosis, day 5
— Answer: CEA within 14 days + antiplatelet + statin
— Vignette: 35-year-old with stroke after chiropractic manipulation, Horner sign
— Answer: carotid/vertebral dissection; antiplatelet or anticoagulation × 3–6 months
— Vignette: NIHSS 2 stroke or ABCD² 5 TIA
— Answer: DAPT (aspirin + clopidogrel) × 21–90 days, then step down
— Vignette: pure motor hemiparesis, lacune on MRI, HTN, DM
— Answer: antiplatelet monotherapy + BP <130/80; NOT long-term DAPT
— Vignette: 42-year-old, cryptogenic stroke, large PFO with septal aneurysm
— Answer: percutaneous PFO closure + antiplatelet
— Vignette: young woman with stroke, prior miscarriages, livedo
— Answer: confirm with repeat antibodies at 12 weeks, anticoagulate with warfarin (not DOAC)
— Vignette: stroke survivor with homonymous hemianopia wants to drive
— Answer: counsel against, document, formal visual field testing
— Vignette: 85-year-old with AF, frequent falls
— Answer: anticoagulate with apixaban (often dose-reduced 2.5 mg BID); falls alone not a contraindication
Step 3 management: When in doubt on a stroke prevention vignette, choose the answer that (1) matches antithrombotic to etiology, (2) adds high-intensity statin, (3) achieves BP <130/80, and (4) completes etiologic workup before labeling cryptogenic. These four moves resolve >80% of Step 3 prevention items.
Secondary prevention of ischemic stroke is etiology-driven: match the antithrombotic to the cause, layer on high-intensity statin and BP <130/80, complete the workup before calling it cryptogenic, and revascularize symptomatic carotid stenosis within 14 days.
— Etiology dictates antithrombotic: AF → DOAC (apixaban preferred); large-artery or lacunar or cryptogenic → antiplatelet monotherapy; minor stroke/high-risk TIA → DAPT × 21–90 days then step down; mechanical valve or triple-positive APS → warfarin. Never use aspirin alone for AF and never use DOACs for APS or mechanical valves.
— Targets to memorize: BP <130/80 (thiazide + ACEi per PROGRESS), LDL <70 on high-intensity statin (SPARCL/TST), A1c ~7% with metformin + GLP-1 agonist or pioglitazone (IRIS) for stroke benefit, smoking cessation as highest-yield modifiable risk factor.
— Don't miss the workup: MRI brain with DWI, CTA head and neck, TTE (+ TEE if cryptogenic or PFO suspected), 30-day ambulatory monitor or loop recorder before labeling cryptogenic (CRYSTAL-AF), and antiphospholipid antibodies confirmed at 12 weeks in young/female patients with thrombosis or pregnancy loss.
— Procedural windows and disposition: CEA within 14 days for symptomatic 70–99% carotid stenosis; PFO closure for cryptogenic stroke in patients <60 with high-risk features (CLOSE/REDUCE/RESPECT); start anticoagulation after cardioembolic stroke per 1-3-6-12 rule; arrange 7–14 day post-discharge follow-up, screen for depression with PHQ-9, address driving safety, and document capacity and goals of care for every stroke survivor before they leave your office.
Board pearl: If you remember only one thing — etiology determines therapy, and "stroke on aspirin" in an AF patient is never the right long-term plan.