Acute Secondary Prevention of Ischemic Stroke: Overlooked No Longer

Zachary B Bulwa,James R Brorson,Scott J Mendelson

doi:10.3389/fneur.2021.701168

Abstract

Recent studies of interventions initiated acutely following onset of minor ischemic stroke or transient ischemic attack (TIA) have disclosed early stroke recurrence rates that are substantially higher than long-term recurrence rates and that can be reduced by acute antiplatelet treatment interventions. These observations, bolstered by analysis based on kinetic modeling of the time course of recurrence following initial events, suggest that acute stroke patients experience an underlying vulnerable state that quickly transitions to a more stable state. Some evidence also supports the benefits of early treatment with direct-acting oral anticoagulants in cardioembolic stroke and of continuation or early initiation of statin therapy in atherosclerotic stroke. Treatment of ischemic stroke should address the transient vulnerable state that follows the initial event, employing measures aiming to avert early recurrence of thromboembolism and to promote stabilization of vulnerable arterial plaque. These measures constitute acute secondary prevention following ischemic stroke.

Highlights

In the hospital care of acute ischemic stroke patients, initial clinical management is tightly focused on interventions aimed to reverse ischemia through induced reperfusion and to limit early complications of brain infarction
Trials of acute treatment of minor ischemic stroke or transient ischemic attack (TIA) with augmented antiplatelet regimens, such as CHANCE (Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events) [5], SOCRATES (Acute Stroke Or Transient IsChaemic Attack TReated With Aspirin or Ticagrelor and Patient OutcomES) [6], POINT (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) [7], and THALES (Transient IscHaemic Attack Treated With TicAgreLor and ASA for PrEvention of Stroke and Death) [8], with randomization and tracking of subjects occurring within 12–24 h of stroke onset, have demonstrated a clear and consistent finding: the stroke recurrence rate is highest within the first few days following stroke, slowing to a second phase of lower recurrence rate, sustained over subsequent months
One-quarter to one-third of ischemic strokes remain unexplained after standard inpatient etiologic evaluations

Summary

INTRODUCTION

In the hospital care of acute ischemic stroke patients, initial clinical management is tightly focused on interventions aimed to reverse ischemia through induced reperfusion and to limit early complications of brain infarction. Investigations are undertaken to rapidly explore potential mechanisms of stroke, and planning for discharge quickly begins, with selection of the appropriate rehabilitation program to meet the patient’s needs. Careful consideration of preventing a subsequent stroke is often relegated to the ambulatory setting. Secondary prevention needs to be considered acutely, as the highest risk for recurrent stroke is typically in the first several days following an initial ischemic event [1, 2]. Risks of early recurrence depend on the subtype of ischemic stroke and on individual patient features, and acute interventions to prevent recurrence need to be targeted to the specifics of each case

ANTIPLATELET TREATMENT IN MINOR STROKE OR TRANSIENT ISCHEMIC ATTACK

Hemorrhage rates

CERVICAL CAROTID ARTERY DISEASE MANAGEMENT

Findings

CRYPTOGENIC STROKE