Overall, secondary stroke prevention includes a multifactorial approach. This article incorporates evidence from guidelines and published studies and uses an illustrative case study throughout the article to provide examples of secondary prevention management of stroke risk factors.

Objectives: Age and stroke severity are major determinants of stroke outcomes, but systematically incorporating these prognosticators in the routine practice of acute ischemic stroke can be challenging. We evaluated the effect of an index combining age and stroke severity on response to IV tissue plasminogen activator (tPA) among patients in the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke trials. Methods:We created the Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index by combining age in years plus NIH Stroke Scale (NIHSS) $100. We applied the SPAN-100 index to patients in the NINDS tPA stroke trials (parts I and II) to evaluate its ability to predict clinical response and risk of intracerebral hemorrhage (ICH) after thrombolysis. The main outcome measures included ICH (any type) and a composite favorable outcome (defined as a modified Rankin Scale score of 0 or 1, NIHSS #1, Barthel index $95, and Glasgow Outcome Scale score of 1) at 3 months. Bivariate and multivariable logistic regression analyses were used to determine the association between SPAN-100 and outcomes of interest.Results: Among 624 patients in the NINDS trials, 62 (9.9%) participants were SPAN-100 positive.Among those receiving tPA, ICH rates were higher for SPAN-100-positive patients (42% vs 12% in SPAN-100-negative patients; p , 0.001); similarly, ICH rates were higher in SPAN-100-positive patients (19% vs 5%; p 5 0.005) among those not receiving tPA. SPAN-100 was associated with worse outcomes. The benefit of tPA, defined as favorable composite outcome at 3 months, was present in SPAN-100-negative patients (55.4% vs 40.2%; p , 0.001), but not in SPAN-100-positive patients (5.6% tPA vs 3.9%; p 5 0.76). Similar trends were found for secondary outcomes (e.g., symptomatic ICH, catastrophic outcome, discharge home). Conclusion:The SPAN-100 index could be a simple method for estimating the clinical response and risk of hemorrhagic complications after tPA for acute ischemic stroke. These results need further confirmation in larger contemporary datasets. Neurology â 2013;80:21-28 GLOSSARY AR 5 attributable risk; AUC 5 area under the curve; CI 5 confidence interval; ECASS 5 European Cooperative Acute Stroke Study; HAT 5 Hemorrhage after Thrombolysis; ICH 5 intracerebral hemorrhage; mRS 5 modified Rankin Scale; NIHSS 5 NIH Stroke Scale; NINDS 5 National Institute of Neurological Disorders and Stroke; NNH 5 number needed to harm; NNT 5 number needed to treat; OR 5 odds ratio; PAR 5 population attributable risk; ROC 5 receiver operating characteristic; sICH 5 symptomatic ICH; SPAN 5 Stroke Prognostication using Age and NIH Stroke Scale; tPA 5 tissue plasminogen activator; UCSD 5 University of California, San Diego.Age and stroke severity are the 2 most important determinants of stroke outcomes.