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  • Review Article
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Secondary stroke prevention

Nature Reviews Neurology volume 6, pages 477–486 (2010)Cite this article

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Abstract

Secondary stroke prevention can reduce the risk of recurrent stroke by ≈90%. To achieve such a reduction, early implementation of preventative measures and administration of therapy appropriate to the underlying cause of the presenting transient ischemic attack or stroke are crucial. Smoking cessation and a Cretan Mediterranean diet are each more effective than any single medication in reducing the risk of recurrent stroke. Control of resistant hypertension can markedly reduce the risk of intracerebral hemorrhage and lacunar infarction but might require therapy that is specific to the underlying cause. New antiplatelet agents have been developed or are in development that might avoid the issues of resistance and drug interactions that prevail with established agents of this type. Furthermore, new anticoagulants in development offer promise of replacing warfarin, and devices to occlude the atrial appendage are on the horizon for patients with atrial fibrillation. Carotid endarterectomy is appropriate for severe symptomatic carotid stenosis, while stenting might be appropriate for symptomatic stenosis where the surgical risk is high. Most patients with asymptomatic stenosis, however, should be treated with medical therapy, unless indicators of high stroke risk are present. In this narrative Review, I discuss recent advances in secondary stroke prevention.

Key Points

  • The risk of recurrent stroke can be reduced by ≈90% with the implementation of secondary stroke preventative measures

  • Lifestyle intervention is vital to secondary stroke prevention: smoking cessation and a Mediterranean diet are each more effective than any single medication in lowering the risk of recurrent stroke

  • Measurements of plasma renin and aldosterone can aid the identification of the cause of resistant hypertension and, hence, the selection of appropriate therapy

  • New antiplatelet agents and anticoagulants that promise to improve therapy for secondary stroke prevention are on the horizon

  • Carotid endarterectomy is safer than carotid stenting, although stenting might be an appropriate treatment for high-risk symptomatic carotid stenosis in patients for whom surgery is risky

  • Carotid stenting and endarterectomy are both inappropriate treatments for most patients with asymptomatic carotid stenosis

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Figure 1: The physiology of therapy for resistant hypertension.
Figure 2: White thrombus in the retinal artery of a patient with amaurosis fugax.
Figure 3: Transcranial Doppler embolus detection.
Figure 4: Imaging of vulnerable plaque.

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J. D. Spence has received honoraria for speaking and research support from Boehringer Ingelheim, Merck, Pfizer, Sanofi-Synthelabo and Wyeth. He has also acted as a consultant for Boehringer Ingelheim.

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Spence, J. Secondary stroke prevention. Nat Rev Neurol 6, 477–486 (2010). https://doi.org/10.1038/nrneurol.2010.114

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