Long-term prevention of ischaemic stroke and stroke recurrence

Stroke is the third most important cause of mortality, but the leading cause of severe handicap, dependency, and loss of social competence. Because of the high recurrence rate, active secondary prevention is mandatory once a stroke has occurred. Secondary prevention of stroke implies the primary prevention of cardiovascular disorders as well. Among the modifiable risk factors hypertension is worst and should be normalized according to recent WHO criteria, also in the elderly. Smoking is another major risk factor and hard to delete. Diabetes mellitus and hyperlipidaemia are also important risk factors and should be treated consequently by diet and medication. Moderate alcohol intake, normalization of body weight and regular physical activity also contribute considerably to prevention of stroke. Whether hyperhomocysteinaemia should be normalized has not yet been clarified. Cardiovascular disorders are an important source of ischemic strokes, particularly atrial fibrillation. Low dose anticoagulation can dramatically reduce stroke risk. Carotid endarterectomy in symptomatic stenoses is the most expensive means of stroke prevention. In less severe stenoses, or ICA occlusions, antiplatelet agents are the treatment of choice. Composite drugs with ASS and other antiplatelet agents seem to be superior to either compound alone. Dissections of the cervical arteries should not be operated on but may be treated by anticoagulation or antiplatelet agents in the acute and subacute phase. The potency of a consequent and comprehensive stroke prevention in preventing disability and death is much greater than any sophisticated acute stroke treatment.