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Note: Antithrombotic
Risk factors may sometimes not help in the diagnosis: Stroke event Hospital Anticoagulant
Hypertension, diabetes, hypercholesterolemia are risk factors for
both infarct & hemorrhagic stroke
Clinically, one may be able to determine the mechanism of stroke Beyond 3 hours → permanent damage
- Hx of transient ischemic attack: Infarction
- Depressed/ alteration of consciousness: Hemorrhagic Acute Ischemic Stroke Treatment in 2007
- Neck rigidity (Because of presence of blood in the
Local Cerebral Blood Flow
Stroke Unit Scare vs. Conventional Care Proven for Proven for
- Stroke units show to be better in outcome in 20 trials when it Primary Prevention Secondary Prevention
comes to death, dependency or in-hospital stay Beta-Blockers ACE-I +
Diuretics Diuretics
Thrombolysis Ca2+ Antagonist ARBs
- IV rtPA ACE-I
- The only FDA approved therapy for treatment of patients ARBs
with acute ischemic stroke
- For patients with acute ischemic stroke <3hours
- IA rtPA AntiHPN trials with Stroke Outcome
- Experimental
- Option for treatment for selected patients with major stroke Trials Year Drug Primary Secondary RR
<6 hours duration due to large vessel occlusion of the Prevention Prevention
middle cerebral artery HOPE 2000 Ramipril vs. X 22%
- Established as a treatment in acute ischemic stroke for patients Placebo
seen within 3 hours of stroke onset PROGRESS 2001 Perindopril X 43%
- The first evidence of benefit from RCTs was provided by the +
NINDS rt-PA stroke study published in 1995 Indapamide
- A meta-analysis of randomized studies has shown that t-PA vs. Placebo
reduces the chance of an unfavourable outcome with an odds LIFE 2002 Losartan X 25%
ratio of 0.66 (95% Cl 0.53 to 0.83) when given within 3 hours of vs. Atenolol
stroke onset MOSES 2005 Eprosartan X 25%
vs. *IDR
Thrombolysis in acute ischemic stroke: Nitrendipine
Controlled trials and clinical experience ONTARGET 2008 Teimisartan X
- rtPA better than placebo TRANSCEND Nitrendipine
combination
Thrombolysis
- Thrombolysis provide benefit only if there is persisting arterial New Treatment for Intracerebral Hemorrhage
occlusion, and there is persisting “ischemic penumbra” - Recombinant activated factor VIIa (rFVIIa)
- A series of careful PET studies has demonstrated that - Hemostatic agent approved for hemophilia (NovoSeven)
penumbral tissue may persist many hours after acute stroke - 3-hour time window
onset, and sometimes even beyond 10 hours - Decrease enlargement of the hematoma
- Improve survival and favourable clinical outcomes
- Potential thrombotic complications (arterial thromboembolic
events) – 7%
- FDA approval pending due to this safety issue
TREATMENT STRATEGIES
- Stroke unit: decrease morbidity & mortality
- Stroke team – mostly neurologists
- Hyperacute
Onset of stroke → 3hrs
Golden period ≤ 3hrs
- Acute: within the first 48hrs
- Prevention:
10% will develop recurrence
An average of 15hrs before pxs are brought to the hospital
75% will be given water in case of acute stroke
- This is bad because 60% of acute stroke has
dysphagia & which may develop aspiration pneumonia
Massage – given next after water
Thrombolytics
- Recombinant tPA: the only FDA approved tx for acute ischemic
stroke
- Must be given within 3hrs (IV)
- > 3hrs - ≤ 6hrs (intraarterial catheterization)
- Disadvatages:
Time: should be given within a specified time
Cost: 1 vial = 48T
6% has a complication of bleed in the brain: “hemorrhagic
conversion from infarct”