In this chapter, we discuss mainly secondary prevention for stroke, although many of the measures, especially control of risk factors and lifestyle changes such as not smoking, controlling blood pressure, etc., are also important measures to avoid a first stroke.

Initially, we discuss a tailored diagnostic work-up, then general measures for secondary prevention of ischemic stroke, and finally recommendations for specific conditions that are associated with a high risk of stroke.

Investigations

The goal of the “stroke work-up” is to find the cause of the stroke in order to determine the best treatment options to maximize the chance of preventing another stroke.

A thorough ischemic stroke work-up is not just CT/MRI/MRA/ECHO/CAROTIDS/TCD/LIPIDS/HBA1C.

There is no “cookbook” work-up for ischemic stroke. It is important to consider the patient's risk factors and stroke syndrome when determining the extent of the diagnostic evaluation. For instance, a 75-year-old man with longstanding hypertension, diabetes, and hypercholesterolemia and a lacunar infarct confirmed on brain imaging may need little additional work-up beyond a carotid ultrasound and EKG. However, a 40-year-old man with no known risk factors and an acute stroke would require an extensive evaluation.

The following is a list of the studies that we consider in most stroke patients to distinguish stroke subtype and tailor our preventive measures. In Appendix 12 we will address the additional evaluation for young stroke patients with no risk factors, and others where the underlying cause may be more obscure.