Background

• Also called brain attack, is a cerebrovascular event, happens when blood flow is blocked by thrombus (stroke) or a ruptured blood vessel (hemorrhage).
• A stroke can be cardioembolic (the embolus or clot forms in the heart and travels to brain) or non-cardioembolic (origin is in the brain).
• Acute ischemic stroke is more common than hemorrhagic stroke (ICH - intracerebral, SAH- subarachnoid).
• Risk factors: HTN (leading cause), AFib, gender, Ethnicity, Age, Cardiac disease, DM, TIA (transient ischemic attack), h/o stroke, Smoking, Hyperlipidemia, Elevated Hematocrit
• S/Sx: Sudden numbness/weakness of face, arm, leg, on one side of body (hemiplegia, hemiparesis); Sudden confusion, slurred speech; Sudden trouble seeing; Sudden trouble walking, balance; Sudden severe HA
• Goal: Maintain cerebral perfusion, control BP, remove/dissolve clot (Activase)

 Act F.A.S.T

• Face: ask patient to smile
• Arms: raise both arms
• Speech: repeat a simple sentence
• Time: call 911 immediately, brain cells are dying

 

Acute management

Drugs: alteplase (t-PA, Activase)

• MOA: Binds to fibrin in a thrombus (clot), convert plasminogen to plasmin, result in fibrinolysis.
• It is the only fibrinolytic agent used in acute ischemic stroke, and can be used w/in 3 hours of symptom onset, when clots show on brain imaging. BP must be < 185/110.
• SE: bleeding, hypotension, intracranial hemorrhage (due to HTN, important to keep low).

 

Secondary prevention

• Correct risk factors: HTN, DM, lipids, Afib, lifestyle modification.
• Anti-hypertensive: ACEI and thiazide diuretics are recommended in stroke prevention. Goal BP < 130/90.
• AFib: for cardioembolic stroke due to AFib, use anticoagulants (not antiplatelets) to prevent future strokes.
• DM: screen for diabetes, A1C is the preferred test.
• Dyslipidemia: follow the guidelines on treatment of blood cholesterol.
• Antiplatelets: for non-cardioembolic ischemic stroke or TIA, use an antiplatelet (not anticoagulant).

 

Anti-platelet therapy

• Drugs: ASA, dipyridamole/ASA (Aggrenox), or clopidogrel (Plavix, if allergic to ASA).
• MOA: ASA irreversibly inhibits COX 1 & 2, results in ↓ prostaglandin and thromboxane A2 production (TXA2, potent vasoconstrictor and platelet inducer). Dipyridamole inhibits the uptake of adenosine into platelet; clopidogrel is a prodrug irreversibly inhibits P2Y12 ADP mediated platelet aggregation.
• Non-cardioembolic stroke or TIA: use an antiplatelet agent, rather than anticoagulation.
• ASA + clopidogrel combo therapy is only used short term after a minor ischemic stroke, to reduce the risk of hemorrhage. This is different than the dual antiplatelet therapy from ischemic heart diseases (ACS).
• DI: avoid clopidogrel with omeprazole and esomeprazole (2C19 inhibitors, prevention conversion of clopidogrel to its active form), other PPIs interact less.

 

Intracranial hemorrhage (ICH)

• Mannitol: produces osmotic diuresis by ↑ the osmotic pressure in the glomerulus of kidney; ↓ ICP by draining water from brain.

Acute subarachnoid hemorrhage

• Nimodipine: a DHP CCB, is used to prevent vasospasm, it is more selective for cerebral arteries due to high lipophilicity.

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