Submodule
Mechanism and Diagnostic Ownership
A prevention plan is only as specific as its causal model. Brain, arteries, heart, rhythm, exposure, and focused alternative-cause testing must converge on a defensible mechanism.
- Etiologic classification
- TIA evaluation
- Infarct pattern
- Prolonged rhythm monitoring
- Adherence assessment
Lacunar, cortical, borderzone
Plaque, stenosis, dissection
AF, thrombus, valve, shunt
Do not order panels without a hypothesis
Treat TIA as an emergency mechanism warning
Transient focal symptoms can resolve while the causal stenosis, embolic source, or small-vessel process remains active. Evaluate brain tissue, extra and intracranial vessels, rhythm, pressure, glucose, and mimics urgently rather than waiting for a routine visit.
Read the infarct as a map, not a verdict
A cortical pattern raises embolic probability, a small deep infarct supports penetrating-vessel disease, a borderzone pattern raises hemodynamic questions, and multifocal territories suggest a proximal source. Each pattern changes probability but still requires vascular and cardiac correlation.
Search for AF in proportion to the question
Telemetry captures only a short interval. Ambulatory or implantable monitoring detects more paroxysmal AF when an embolic event remains unexplained. Choose duration according to pretest probability, patient feasibility, and whether detection would change anticoagulation.
Verify exposure before declaring failure
A medication listed in the chart may never have reached the patient. Reconstruct dispensing, administration, missed doses, swallowing, adverse effects, cost, cognition, beliefs, interactions, and caregiver support before changing therapy after recurrence.
Quick check
Submodule
Noncardioembolic Antiplatelet Therapy
Long-term single antiplatelet therapy is the default for noncardioembolic prevention, while dual therapy belongs to narrow early indications with an explicit stop date.
- Aspirin
- Clopidogrel
- Aspirin with extended-release dipyridamole
- Short-course DAPT
- Combination boundaries
Long-term noncardioembolic prevention
Stop on schedule
Time by infarct and bleeding
Bleeding without a prevention target
Select one durable antiplatelet strategy
Aspirin, clopidogrel, and aspirin with extended-release dipyridamole are established options. Selection depends on bleeding history, GI tolerance, allergy, headache, CYP2C19 interactions, formulation, swallowing, adherence, cost, and concurrent vascular indications.
Use early DAPT as a time-limited intervention
Aspirin plus clopidogrel reduces early recurrence in selected minor noncardioembolic stroke or high-risk TIA. Benefit is concentrated early, while bleeding rises with prolonged exposure. Document the qualifying event, start time, planned duration, and single-agent transition.
Treat severe symptomatic intracranial disease medically first
Aggressive medical management includes selected short-course DAPT, pressure control, intensive lipid lowering, diabetes and tobacco treatment, activity, and adherence. Routine intracranial angioplasty or stenting is not first-line recurrence prevention.
Do not stack antithrombotics without a second indication
Long-term DAPT is not routine, and antiplatelet plus anticoagulant therapy is usually not indicated solely for stroke prevention. A coronary stent, vascular procedure, or another condition may create a separate indication, but purpose and duration must remain explicit.
Quick check
Submodule
Cardioembolic Anticoagulation
Anticoagulation choice and timing require the embolic source, infarct biology, hemorrhage risk, valve status, organ function, product-specific dosing, interaction, and adherence context.
- Atrial fibrillation
- Start timing
- DOAC dosing
- Mechanical valves
- Ventricular thrombus
More monitoring finds more AF
Do not treat all valves alike
Repeat imaging when needed
Missed doses rapidly remove protection
Anticoagulate eligible atrial fibrillation
Most survivors with AF should receive anticoagulation when not contraindicated. Antiplatelet therapy alone does not provide equivalent cardioembolic protection. Rhythm evidence, infarct, hemorrhagic transformation, kidney and liver function, valve status, bleeding, interactions, adherence, and cost shape selection.
Time initiation to the brain, not only the rhythm
Early anticoagulation reduces the interval of recurrent embolic risk, but a large infarct or hemorrhagic transformation can make early treatment dangerous. Use neurologic severity, infarct size, imaging evolution, reperfusion exposure, bleeding, and repeat imaging rather than a universal start day.
Dose each DOAC as its own product
Apixaban, rivaroxaban, dabigatran, and edoxaban use different renal measures, reduction criteria, food instructions, interaction rules, and dosage forms. Calculate the required renal estimate and apply the current label. Unjustified underdosing can lose protection without eliminating bleeding.
Respect conditions that still require warfarin
Mechanical prosthetic valves require vitamin K antagonist therapy with valve-specific INR management. Ventricular thrombus requires coordinated treatment and repeat imaging. The medication, cardiac source, duration, monitoring, and concurrent antiplatelet need should never be inferred from the word cardioembolic alone.
Quick check
Submodule
Atherosclerotic and Structural Sources
Symptomatic carotid and intracranial disease demand causal localization and intensive medical therapy, with intervention chosen only for evidence-based anatomy and patient fit.
- Symptomatic carotid stenosis
- CEA versus stenting
- Intracranial stenosis
- LDL lowering
- Blood-pressure control
Early endarterectomy in suitable severe disease
Stenting is not first line
Add nonstatin when needed
Individualize safely
Treat the symptomatic ipsilateral carotid lesion
Suitable patients with recent nondisabling stroke or TIA and severe ipsilateral extracranial carotid stenosis benefit from relatively early intervention. Confirm stenosis method, event territory, disability, timing, anatomy, medical therapy, life expectancy, and center outcomes.
Choose CEA or stenting through anatomy and risk
Endarterectomy and stenting differ in perioperative stroke, myocardial, cranial-nerve, access, and antiplatelet considerations. Age, arch and lesion anatomy, prior neck surgery or radiation, restenosis, cardiac disease, and operator performance determine the safer strategy.
Use aggressive medical therapy for intracranial disease
Severe symptomatic intracranial stenosis receives short-course DAPT when indicated plus intensive pressure, lipid, diabetes, tobacco, exercise, and adherence care. Routine angioplasty and stenting are not the first step, even when the image looks dramatic.
Control cumulative vascular exposure
For most survivors with atherosclerotic disease, use high-intensity statin therapy and an LDL goal below 70 mg/dL, adding ezetimibe and then considering a PCSK9 inhibitor when needed. A pressure goal below 130 over 80 is appropriate for most patients when safely tolerated.
Quick check
Submodule
Special Mechanisms and Uncertain Source
PFO, ESUS, dissection, and small-vessel disease require specific causal reasoning. Uncertainty is a reason to maintain diagnostic ownership, not to escalate empirically.
- PFO closure
- ESUS
- Cervical dissection
- Small-vessel disease
- Focused testing
Prove plausible causality
Continue diagnostic ownership
Individualize bleeding and anatomy
Do not search for a large embolus forever
Close only a plausibly causal PFO
PFO is common. Closure is reasonable in selected younger patients with a nonlacunar embolic event, no better cause, and higher-risk shunt anatomy. Complete vessel and rhythm evaluation and use neurology-cardiology shared decision-making that includes procedural AF and device risks.
Do not empirically anticoagulate ESUS
Embolic stroke of undetermined source is a diagnostic category, not a single disease. Trials do not support routine anticoagulation or ticagrelor for the group. Use antiplatelet therapy and continue targeted rhythm, cardiac, vascular, malignancy, and aortic evaluation when clinically justified.
Treat dissection as a wall injury
Cervical artery dissection differs from atherosclerotic carotid disease. Select antiplatelet or anticoagulant therapy according to infarct, anatomy, intracranial extension, pseudoaneurysm, bleeding, and patient context, then assign follow-up imaging and activity counseling.
Recognize small-vessel prevention
A compatible small deep infarct supports penetrating-vessel disease. Prevention centers on single antiplatelet therapy and intensive pressure, diabetes, lipid, tobacco, sleep, and activity care. Long-term DAPT adds bleeding without routine lacunar benefit.
Quick check
Submodule
Lifelong Risk and Recurrence Care
A technically correct discharge list prevents little unless the patient can obtain, understand, perform, tolerate, monitor, and sustain the plan in daily life.
- Mediterranean-style diet
- Safe physical activity
- Tobacco treatment
- Rehabilitation and mood
- Access and recurrence response
Track control over time
Advice alone is insufficient
Investigate adherence before switching
TIA is not a routine visit
Use a behavior system, not advice alone
Low-sodium or Mediterranean-style eating, safe physical activity, tobacco cessation, sleep treatment, and medication adherence improve only when goals are specific, barriers are assessed, progress is measured, and multidisciplinary support continues. A brochure is not a longitudinal intervention.
Make activity and rehabilitation safe and possible
Mobility, language, vision, cognition, fatigue, pain, depression, and fear can limit prevention activity. Physical, occupational, speech, cognitive, swallowing, and psychological care should align with the patient's functional goals and environment.
Treat social conditions as clinical constraints
Cost, transportation, food access, housing, work, caregiving, health literacy, language, device access, and pharmacy availability shape exposure. Simplify regimens and connect real resources rather than documenting noncompliance without investigation.
Prepare for recurrence before it occurs
New focal symptoms are an emergency even if they resolve. Teach recognition, emergency activation, last-known-well recording, medication and bleeding information, and avoidance of self-directed extra antithrombotic doses. Assign follow-up for pending tests and risk targets.
Quick check
Module test
Check the connections.
Each attempt draws 10 questions from the complete 104 question bank.
Each attempt draws a fresh set and rearranges the answer choices.
References
Current clinical foundation.
Lecture material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.