STROKE

Unit IX
STROKE
● Leading cause of disability in adults
● “Brain Attack”
● Blood clot blocks an artery or a blood
vessel, or breaks → interrupting blood flow
to an area of the brain → Cells begin to die
and brain damage occurs.
Types of Stroke
● ISCHEMIC STROKE (87%) ● HEMORRHAGIC STROKE (13%)
Ischemic Stroke
● Thrombotic Stroke
○ when damaged cerebral
arteries become blocked by the
formation of a blood clot within
the brain
● Embolic Stroke
○ caused by a blood clot that
develops elsewhere in the body
and then travels to one of the
blood vessels in the brain
through the bloodstream.
○ Atrial Fibrillation
■ HR 100-175 bpm
Hemorrhagic Stroke
● Subarachnoid hemorrhage
○ when blood enters the
subarachnoid space
■ Trauma
■ Rupture intracerebral aneurysm
■ Rupture of arteriovenous
malformation (AVM)
Hemorrhagic Stroke
● Intracerebral hemorrhage
○ when bleeding occurs in the
brain parenchyma itself, with
the formation of a hematoma
within the brain.
■ Uncontrolled hypertension
■ Antithrombotic therapy
■ Cerebral amyloid angiopathy
■ Drug of abuse
Hemorrhagic Stroke
● Subdural hematomas
○ Collections of blood below the
dura.
■ Trauma
Non-modifiable Risk Factors
❏ Age
❏ Gender
❏ Race (African-American, Asia-Pacific Islanders, Hispanic)
❏ Family history of stroke
❏ Low birth weight
Modifiable Risk Factors
❏ Hypertension ❏ Asymptomatic carotid stenosis
❏ Atrial Fibrillation ❏ Postmenopausal hormone
❏ Other Cardiac Diseases therapy
❏ Diabetes Mellitus ❏ Lifestyle factors
❏ Dyslipidemia
❏ Cigarette Smoking
❏ Alcohol
❏ Sickle cell disease
 Clinical
Presentation
Clinical Presentation
● Stroke
○ Abrupt-onset focal neurologic deficit that lasts at least 24 hours and is of
presumed vascular origin
■ Speech, vision, hearing problems
■ Weakness in the left arm
■ Paresis
■ Plegia
Clinical Presentation
● Transient ischemic attack (TIA)
○ “Mini stroke”
○ Lasts <24 hours and usually less than
30 minutes.
○ Without evidence of infarction
Symptoms
● Ischemic stroke
● Weakness on one side of the
○ Headache
body
● Hemorrhagic stroke
● Inability to speak
○ Very severe pain and
● Loss of vision
headache
● Vertigo
● Trouble walking
Signs
● Hemiparesis or Monoparesis
● Hemisensory deficit
● Patients with vertigo and
double vision are likely to
have posterior circulation
involvement.
● Aphasia is seen commonly in
patients with anterior
circulation strokes.
● Dysarthria
● Altered levels of
consciousness
Laboratory Tests ● Tests for hypercoagulable states
○ Done only when the cause of
Acute Strokes:
the stroke cannot be
● Blood glucose test determined based on the
● Platelet count presence of well-known risk
● Coagulation test factors for stroke
■ Protein C deficiency

■ Protein S deficiency

■ Antiphospholipid antibody
Diagnostic Tests
● CT scan
○ Reveal an area of hyperintensity
(white) in hemorrhage and will be
normal or hypointense (dark) in the
area of infarction.
● MRI
○ Reveal areas of ischemia with higher
resolution.
Diagnostic Tests
● Diffusion Weighted Imaging (DWI)
○ Reveal an evolving infarct within minutes on stroke
onset
● Carotid Doppler (CD)
○ Determine whether the patient has a high degree of
stenosis in the carotid arteries supplying blood to
the brain.
● Electrocardiogram (ECG)
○ determine whether the patient has atrial fibrillation
Treatment
Desired Outcomes
❏ Reduce the ongoing neurologic injury and decrease mortality and
long-term disability
❏ Prevent complications secondary to immobility and neurologic
dysfunction
❏ Prevent stroke recurrence
General Approach
● Respiratory and cardiac support
● Determine quickly whether the lesion is ischemic or hemorrhagic by
CT scan
● Ischemic stroke patients presenting within hours of symptom onset
should be evaluated for reperfusion therapy.
●
General Approach
● Patients with ↑BP should remain untreated unless
○ BP > 220/120 mm Hg
○ evidence of aortic dissection, acute myocardial infarction (AMI), pulmonary
edema, or hypertensive encephalopathy.
● If BP is treated in the acute phase, short-acting parenteral agents (e.g.,
labetalol, nicardipine, nitroprusside) are preferred.
Pharmacologic ● Labetalol 10-20 mg IV over 1-2 minutes, may repeat
options for ● Nicardipine 5 mg/hr IV, titrate up by 2.5 mg/hr every 5-15
lowering BP in
Acute Stroke
minutes, maximum 15 mg/hr
● Clevidipine 1-2 mg/hr IV, titrate by doubling the dose every
2-5 minutes, maximum 21 mg/hr
● Other agents to consider: hydralazine, enalaprilat,
nitroprusside IV infusion, labetalol IV infusion
Ischemic stroke Pre-alteplase:
w/ Alteplase ● Lower SBP <185 and DBP <110
Post-alteplase:
● Maintain SBP <180 and DBP <105 for 24 hrs.
Ischemic stroke ● Treatment benefit uncertain/not recommended unless BP >220/120 mmHg
w/o Alteplase ● Lowering BP by 15% is probably safe when required by comorbid conditions
(such as concomitant acute coronary event, acute heart failure, aortic
dissection, symptomatic intracranial hemorrhage, preeclampsia/eclampsia)

Intracranial ● Treatment is reasonable with SBP >220 mm Hg

Hemorrhage ● Patients with SBP 150-220 mm Hg, acute lowering of SBP to 140 mm Hg is
safe
Nonpharmacologic
Therapy
Nonpharmacologic Therapy
● SURGICAL DECOMPRESSION
○ Craniectomy
○ Removal of part of the skull to relieve
pressure on the brain
○ Cases of significant swelling associated
with cerebral infarction
Nonpharmacologic Therapy
● REHABILITATION
○ Very effective in reducing long-term disability
● CAROTID ENDARTERECTOMY
○ Effective in reducing stroke incidence and recurrence.
● CAROTID STENTING
○ Effective in reducing recurrent stroke risk in patients at high
risk of complications with endarterectomy.
Nonpharmacologic Therapy
● In subarachnoid hemorrhage due to a ruptured intracranial
aneurysm or arteriovenous malformation
○ surgical intervention to clip or ablate the vascular abnormality
substantially reduces mortality from rebleeding.
Pharmacologic
Therapy
Acute Treatment of Ischemic Stroke
● INTRAVENOUS t-PA (Alteplase) Adverse effects:
○ Initiated within 4.5 hours of stroke onset ● High risk for bleeding
● ICH
Acute Treatment of Ischemic Stroke
● INTRAVENOUS t-PA (Alteplase)
Inclusion criteria:
● Age ≥18 yrs old
● Clinical diagnosis of ischemic stroke with neurologic deficit
● Time of symptom onset well established to be <4.5 hours from treatment
initiation
Acute Treatment of Ischemic Stroke
● INTRAVENOUS t-PA (Alteplase)
Protocol:
● Alteplase 0.9 mg/kg IV (maximum 90 mg), 10% as a bolus over 1 min. The
remainder given over 1 hour in selected patients
● CT scan to rule out hemorrhage
● Avoidance of antithrombotic therapy (anticoagulant or antiplatelet) for 24
hours after alteplase
● SBP >185, DBP >110 mmHg
Acute Treatment of Ischemic Stroke
● ASPIRIN
○ 168-325 mg daily started within
24-48 hours of stroke onset
○ Onset of effect < 60 mins.
○ Patients receiving alteplase, are
generally held for 24 hours after
alteplase administration to
reduce risk of hemorrhage
Acute Treatment of Ischemic Stroke
● ASPIRIN
Adverse effects:
● GI distress
● GI bleeding

Drug interaction:
● NSAIDs
○ Administer ASA 2 hrs before NSAID or 4
hours after NSAID
Secondary Prevention of Ischemic Stroke
● ANTIPLATELET
○ Noncardioembolic strokes
○ Long-term antithrombic therapy to
patients who have had acute ischemic
stroke and TIA
1st line antiplatelet agents:
● Aspirin (50-325 mg daily)
● Clopidogrel (75 mg daily)
● Extended-release
Dipyridamole + Aspirin
(ERDP-ASA) (200/50 mg BID)
Secondary Prevention of Ischemic Stroke
● ANTIPLATELET
○ Clopidogrel (Plavix)
■ 75 mg daily
■ Adenosine Diphosphate (ADP) inhibitor

Drug interactions: Adverse effects:

● CYP4502C19 inhibitor: ● Diarrhea
○ Omeprazole ● Rash
○ Esomeprazole
Secondary Prevention of Ischemic Stroke
● ANTIPLATELET
○ Extended release Dypiridamole + Aspirin Adverse effects:
■ Phosphodiesterase (PDE) Inhibitor ● May worsen angina,
■ Not used alone
dizziness, headache,
Adenylyl
cyclase PDE syncope, GI
ATP cAMP AMP
disturbances, rash
Antiaggregant
Secondary Prevention of Ischemic Stroke
● ANTIPLATELET
○ Dual antiplatelet Therapy
■ Aspirin + Clopidogrel
● Ultra low dose of aspirin
● Patients with ischemic stroke, history of MI, and
coronary stent placement
Secondary Prevention of Ischemic Stroke
● ANTICOAGULANT
○ Cardioembolic strokes
○ Treatment of choice in patients
with Atrial fibrillation, history of
recent stroke or TIA
● Warfarin
● Dabigatran (150 mg BID)
● Apixaban (5 mg BID)
● Rivaroxaban (20 mg OD)
● Edoxaban (60 mg OD)
Secondary Prevention of Ischemic Stroke
● ANTICOAGULANT ● First 2 days (Procoagulant):
○ Warfarin Warfarin + Heparin
■ Antithrombotic agent of 1st choice for
secondary prevention in patients with Contraindicated:
atrial fibrillation and a presumed
cardiac source of embolism ● Pregnant → Hemorrhagic
■ INR: 2.5 fetal disorder
MOA:
● Inhibits Vit. K epoxide reductase →
↓Factor X, IX, VII, II
Secondary Prevention of Ischemic Stroke
● ANTICOAGULANT
○ Direct Oral Anticoagulant
■ Dabigatran (150 mg BID)
■ Apixaban (5 mg BID)
■ Rivaroxaban (20 mg OD)
■ Edoxaban (60 mg OD)
○ Less food and drug interactions
○ Evaluated patient’s renal function prior to drug therapy
Blood Pressure Management
● Recommended anti-hypertensive agent for patients with stroke and
TIA:
○ ACE inhibitors
Given after the acute
○ Diuretics period (7 days)
○ ARBs - for patients unable to tolerate ACE inhibitor
Statin Therapy
● For all Ischemic stroke patients
● Reduce the risk of stroke by approximately 30% in patients with
coronary artery disease and elevated plasma lipids.
○ Ischemic stroke and TIA = Coronary risk equivalent (National Cholesterol
Education Program (NCEP))
○ LDL goal = <100 mg/dL
Statin Therapy
● Age ≤ 75 years old → High-intensity statin
● Age > 75 years old → Moderate or high-intensity statin
● If the patient is on maximally tolerated statin therapy, but still has
an LDL cholesterol ≥70 mg/dL (1.81 mmol/L) → + Ezetimibe
Heparin
● Low-molecular-weight heparins or
low-dose subcutaneous unfractionated
heparin (5,000 units TID)
○ Recommended for the prevention of
DVT in hospitalized patients with
decreased mobility.
Hemorrhagic Stroke
● Subarachnoid hemorrhage due
to aneurysm is associated with
high incidence of delayed
cerebral ischemia in 2 weeks
after bleeding
● Nimodipine
○ Recommended to reduce
incidence and severity of
neurologic deficits from
delayed ischemia
○ 60 mg every 4 hours, continue
for 21 days
○ If hypotension occurs → 30 mg
every 2 hours
Thank you for
listening!