Reducing salt intake by 3 g per day lowers blood pressure ; the effect is doubled with a 6 gm/day reduction and tripled with a 9 gm/d reduction.
Reduction in stroke risk parallels reduction in salt intake.
Pooled results after 5 years
Pravastatin or Simvastatin 40 mg/day
Changes in cholesterol levels
Total cholesterol decreased 20%
LDL cholesterol decreased 28%
HDL cholesterol increased 5%
Triglycerides decreased 13%
Reducing LDL cholesterol by 1 mmol/L
22% stroke reduction in patients with known vascular disease
6% stroke reduction in patients without known vascular disease
28% reduction in thromboembolic stroke
Goldszmidt and Caplan, Stroke Essentials , Physicians’ Press, 2003
Basing treatment on brain imaging alone without a vascular work-up.
A left frontal stroke caused by tight carotid stenosis requires revascularization , but the same stroke caused by atrial fibrillation requires warfarin .
Basing work-up and treatment on the temporal course of stroke.
Intervention should focus on the vascular lesion. In fact, the same vascular lesion could cause TIA, evolving stroke, or completed stroke.
Overlooking a mimic of TIA or stroke.
19% of patients diagnosed with stroke in ED have an imitator of stroke
Mistaking the time of symptom onset for patients who wake up with stroke.
Strokes are painless and do not wake people up. Because of risk of late thrombolysis , onset time should be assumed to be when they were last awake.
Diffusion-weighted MRI may be helpful in determining benefit/risk of thrombolytic therapy.
Failing to investigate intracranial as well as extracranial circulations.
Emboli or thrombi can come from anywhere in the carotid or vertebrobasilar. Carotid duplex imaging does not investigate the intracranial circulation.
Transcranial doppler or MRA can non-invasively detect intracranial lesions,l more common in African-American and Asian patients.
Failing to distinguish severe carotid stenosis from total occlusion.
Severe stenosis may require urgent surgery ; total occlusion usually requires medical therapy. Neither carotid duplex imaging nor MRA can fully distinguish between the two. Conventional angiography is the test of choice.
Failing to check spinal fluid in patients with suspected subarachnoid hemorrhage.
CT has 90% sensitivity for subarachnoid blood on day of onset, but sensitivity decreases over time. Also, small hemorrhages can be missed.
For patients with suspected SAH who have a negative CT, lumbar puncture is needed.
Considering only embolism in stroke patients with atrial fibrillation.
More than 25% of ischemic strokes in patients with AF have causes other than cardiogenic embolism (e.g. aortic arch atheroma and intrinsic vascular disease).
Other interventions, such as carotid revascularization, may be required.
Overtreating hypertension in acute stroke.
Because autoregulation is lost in ischemic brain, aggressive lowering of BP may cause infarct extension.
Treat BP > 200/120 in absence of thrombolytics or > 180/115 with thrombolytics
Failing to adequate evaluate the heart.
Silent myocardial infarction and arrhythmias are common complications of stroke.
MI occurs in 20% of patients with acute stroke. It is a common cause of death at 1 – 4 weeks.