Management of the Case: 45-year-old Man Presenting with a Stroke

00:01 In this talk, we're going to review the long term treatment and secondary prevention of ischemic stroke.

00:08 So let's start with a case.

00:10 This is a 45-year-old man presenting with stroke.

00:14 45-year-old man with a history of hypertension, hyperlipidemia and diabetes presents for right-sided weakness and speech dysfunction.

00:22 The patient went to bed last night in his normal state of health.

00:25 When the patient awoke this morning his wife says he did not have any symptoms and was able to speak normally.

00:31 Around 10:30 AM, he went to his shed to work in his shop.

00:35 And at around 11:30 AM, she found him in the shed on the ground without the ability to move his right side and mumbling.

00:43 EMS was called him and he was brought to the emergency department, where he remains weak and mumbling since he has been brought into the ED.

00:51 The patient presents with symptoms suggestive of a left MCA syndrome and tPA is administered followed by thrombectomy.

00:59 The patient has improvement in his NIH Stroke Scale from 24 to 5.

01:04 And as you know, the NIH Stroke Scale is really the workhorse for how we evaluate symptoms of a stroke.

01:10 The higher the number, the larger the stroke, the smaller the number, the smaller the stroke and the smaller the disease burden.

01:17 MRI of the brain shows a partial left MCA stroke and workup is otherwise unremarkable.

01:24 So what's the optimal management for stroke prevention in this patient? Let's go back through some of the key details and findings in this case that guide us into how we want to manage this patient.

01:35 First is the symptom onset.

01:37 These were sudden, abrupt or acute onset symptoms, and that should make us think a vascular etiology.

01:44 Next, we think about the evolution over time, the symptoms began suddenly, and have remained fixed, They're the same now as they were right when they started.

01:53 And that's an acute fixed deficit which is also suggestive of a vascular etiology.

01:59 That's what we see with stroke.

02:03 Third, we want to localize the symptoms.

02:05 This patient has right hemiplegia which points to a left hemisphere problem, and aphasia, speech difficulty, mumbling, not getting words out.

02:14 And aphasia is a cortical symptom that really points us to a left MCA territory infarct.

02:22 And then the last important wildcard finding in this case is that his last known normal was at 10:30 AM.

02:29 And in stroke, we really focus on the last time the patient was normal.

02:33 Patients presenting within that first 3 to 4 1/2 hours are candidates for intravenous tPA or thrombectomy as was performed in this case.

02:45 The patient underwent MRI scan of the brain.

02:47 And here we're looking at the diffusion weighted MRI imaging showing a large area of left MCA restricted diffusion.

02:55 And this is the stroke.

02:56 The diffusion weighted image shows us cytotoxic edema swelling within the cells that begins early within minutes after a stroke as a result of loss of the sodium potassium ATPase function.

03:09 And we see that on the diffusion weighted image and those are areas of infarction loss of tissue.

03:17 So what's the optimal management for stroke prevention for this patient presenting with a left MCA ischemic infarct? Aspirin, clopidogrel, anticoagulation or aspirin and clopidogrel? Well, clopidogrel or brand name, Plavix is a common medicine used for secondary stroke prevention.

03:37 But aspirin is really the initial treatment of choice for patients presenting with an acute stroke that aren't currently on antiplatelet therapy.

03:45 For patients with atrial fibrillation, we think about anticoagulation.

03:49 In this case, the patient wasn't on aspirin, and clopidogrel really wouldn't be our first choice for this patient.

03:57 Anticoagulation is also not preferred for this patient.

04:00 We think about initiation of anticoagulation in patients who have atrial fibrillation, or another indication for anticoagulation.

04:08 This patient presented with a large territory infarct, which also increases the risk of hemorrhage with early initiation of anticoagulation.

04:17 So this wouldn't be the preferred treatment of choice for this patient.

04:21 Aspirin and clopidogrel or dual antiplatelet therapy is increasingly used for patients with small or minor strokes or TIA, but not patients with large areas of ischemia such as this patient with his NIH Stroke Scale of 24.

04:36 We consider dual antiplatelet therapy for minor strokes or TIA when there is significant intra or extracranial atherosclerotic disease, and this is not the case for this patient.

04:48 So aspirin is the treatment of choice for this patient.

04:52 Aspirin is the initial antiplatelet treatment for secondary stroke prevention for the majority of patients that present with an acute ischemic stroke.

04:59 It's highly effective in preventing stroke within the first 1-3 months and then for years and it's really the workhorse of secondary stroke prevention for patients with ischemic stroke.

05:09 For patients with atrial fibrillation anticoagulation is favored which was not the case for our patient.