Ischemic Stroke: Treatment

Details

Last actualized November 23, 2016

Lecture Course Stroke (Cerebrovascular Accident)

Lecturer Carlo Raj, MD

Institution Medical Experts

Description
The lecture Ischemic Stroke: Treatment by Carlo Raj, MD is from the course Stroke (Cerebrovascular Accident). It
contains the following chapters: Treatment of Ischemic Stroke, Tissue Plasminogen Activator - tPA, Secondary
Prevention, Ischemic Stroke: Summary.

Comments

Carlo Raj, MD Dear course participants,

November welcome to my course "Stroke (Cerebrovascular Accident)". If there are any

questions, please post them in our forum. I will answer them quickly.
10, 2016
Best regards,
Carlo Raj

Dmitri P. Like your lectures.

November
19, 2016
Anthony M. Hi,
Could you clarify the platelet cut off. You stated below 100,000 as a contraindication
February 8, but then stated below 50,000 contraindicated... thank you

2017 Also, I know it's a newer thing to withhold oxygen in CVA if pulse oximetry is 94% and
above. Will USMLE hold us to that AHA recommendation?

Robert P. Greetings and thank you for your question. tPA is contraindicated in stroke patients
with platelets <100,000/mm^3. I am not sure what Dr. Raj is implying when he
May 7, 2017 mentions 50,000/mm^3. Here is a document on the topic for your review:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530420/

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 Regarding recent changes to AHA recommendations and the USMLE, it is my
understanding that the USMLE will not ask changes on recently changed guidelines or
they will ask it in such a way as to not require an exact number. I hope this answers
your questions.

Good luck with your studies,

Rob
Lecturio Medical Adviser

Dipika P. In the first 30 seconds of this video you speak about blood pressure. What exactly is
the target BP we want to achieve, and what is the limit at which we treat?
August 22,
2017
Robert P. Dear Dipika,

August 25, Thank you very much for your question. The topic of blood pressure management in
acute stroke patients is rather complicated. Thankfully, extensive research has been
2017 done on that subject to determine when blood pressure should be controlled, what
should be your target, and when you should opt for rapid reduction of arterial blood
pressure rather than gradual reduction. The short answer is, such as decision need to
be individualized.

Patients with acute ischemic stroke who are going to acute reperfusion therapy and
who have a blood pressure above 185/110 mm Hg should receive antihypertensive
therapy. The goal is to achieve a blood pressure equal to or below 180/105 mm Hg.
Patients with a blood pressure that is below 185/110 mm Hg will spontaneously have
a slight drop in their blood pressure before the procedure, therefore, antihypertensive
therapy is not indicated.

Patients with a systolic blood pressure above 220 mm Hg or a diastolic blood

pressure between 121 and 140 mm Hg who are not eligible for acute reperfusion
therapy should receive antihypertensive therapy aiming to lower their blood pressure
by 10 to 15%. Therefore, the goal is not to completely normalize the blood pressure. If
the patient belongs to this category but the diastolic blood pressure is above 140 mm
Hg, then sodium nitroprusside is indicated for the rapid reduction of the blood
pressure. Again, you should aim for a 10 to 15% reduction in the blood pressure.

Patients who present with an elevated blood pressure that is above 140/90 mm Hg in
the subacute setting should receive routine blood pressure antihypertensive therapy.
You should aim to reach a level that is below 140/90 mm Hg.

Patients with a recent lacunar stroke should receive antihypertensive therapy as long
as their systolic blood pressure is above 130 mm Hg.

There is a special group of patients who present with acute intracerebral hemorrhage.
Patients in this group who have a systolic blood pressure between 150 and 220 mm
Hg should receive intravenous sodium nitroprusside for the acute reduction of their
blood pressure as this was associated with better outcome. Only in this group of
patients, it is considered as reasonable to achieve a systolic blood pressure of 140
mm Hg in the acute phase.

I hope that this answers your questions. You can have a look on the reference below

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 for more information about the management of blood pressure in stroke patients.

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196458/

Kind regards,
Rob (Lecturio Medical Adviser)

Soumyashree M. Heparin can't be given in stroke caused by blood vessels dissection..why??

July 24, 2018

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