Table 1.
Investigations to avoid missing modifiable vascular risk factors.
| Measure | To detect | |
|---|---|---|
| Modifiable vascular risk factors | ||
| Blood pressure | Hypertension | May need multiple measures, or ambulatory monitoring |
| Blood glucose | Diabetes | |
| Blood lipids | Hyperlipidaemia | |
| Body mass index | Overweight and obesity | |
| Lifestyle history | Excessive alcohol intake, smoking, poor diet, inadequate exercise and sedentary habit | |
| Other proxy-risk factors, as obstructive sleep apnea, homocysteine levels | Different factors associated with higher vascular risk | If not actively searched be a missed opportunity to be identified |
| Sources of emboli and evidence of ischaemic cardiovascular disease: | ||
| ECG | Cardiac arrhythmias, particularly atrial fibrillation; ischaemic heart disease | May need ambulatory monitoring, to detect paroxysmal arrhythmias or even an ECG-T (cardiac event recorder) |
| Echocardiogram | Heart valve disease, atrial septal defects (ASDs)Aortic cross atheroma | Transoesophageal echo with iv echocontrast is more sensitive to ASDs than transthoracic |
| Doppler Ultrasound, CT or MR angiography | Carotid or vertebral artery extra- or intracranial stenosis | CT or MR angiography for suspected intracranial stenosis |
| Evidence of cerebrovascular disease | ||
| MR or CT brain imaginga | Acute or old cortical infarcts;Acute or old subcortical infarcts; acute or old brain haemorrhage; WMH, lacunes, microbleeds, cortical siderosis; brain atrophy including regional distribution | T1-weighted, T2-weighted, FLAIR, SWI and DWI sequences are all essential to assess for the range of cerebrovascular disease lesions. |
aMRI preferred, as more sensitive for detecting vascular changes. CT will detect non vascular causes and brain atrophy, many infarcts, acute haemorrhage, and moderate to severe WMH and lacunes, but not microbleeds, differentiate old infarct from haemorrhage, and is much less sensitive to SVD lesions than is MRI. CT possibilities discriminated in main text.
WMH: white matter hyperintensities; FLAIR: fluid attenuated inversion recovery; SWI: susceptibility-weighted imaging; DWI: diffusion-weighted imaging or diffusion imaging.