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(Circulation 2010;121:e4; Lancet 2008:371:1612)

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  • 3rd most common cause of death after IHD, 9% of global deaths; 25% of ischemic stroke patients die within a month & 50% by 1y
  • Ischemic stroke
    • Progressive accumulation of lipids & inflammatory cells in affected arteries & hypertrophy of arterial smooth muscle create formation of plaque
      • Sheer stress can rupture the plaque creating a clot
      • The clot can cause an occlusion to become an embolism
    • Stasis of blood in the heart can cause a direct embolism to the cerebral circulation
    • Result of clot formation or embolism is arterial circulation blockage leading to ischemia
  • Hemorrhagic stroke: blood causes irritation to brain & mass effect; the larger the blood volume, the more severe the stroke

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Classification

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  • Transient ischemic attack (TIA) (Stroke 2011;42:227) (predictor for ischemic stroke)
    • Transient episode of neurological dysfunction caused by ischemia, not infarction, lasting <24h
    • 90-d risk of stroke after TIA up to 17%, greatest risk in 1st wk
  • Ischemic stroke (87%); hemorrhagic stroke (13%)
  • DDx: migraine, head trauma, brain abscess, encephalitis, brain tumor, seizure with postictal paralysis, hypoglycemia

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(Pharmacotherapy 2010;30:493)

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  • 5 cardinal stroke signs: HA, dizziness, vision impairment, speech impairment, weakness
  • CT scan w/o contrast to r/o hemorrhage & determine size, location, vascular distribution of infarct
  • Neurological deficits determined with National Institutes of Health Stroke Scale (NIHSS) & modified Rankin Scale (mRS)

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Ischemic Stroke

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Treatment Goals: ↓ neurological injury, ↓ M&M, prevent complications & recurrence

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Pharmacological Treatment

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Acute Inpatient Management

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  • Alteplase (rt-PA)
    • IV tissue plasminogen activator (fibrinolytic) with Class I, level A evidence in stroke
    • Efficacy: 30% more likely than placebo to have minimal or no disability at 90d if administered within 3h of symptoms (N Engl J Med 1995;333:1581)
    • Safety: symptomatic intracranial hemorrhage within 36h 6.4% rt-PA vs 0.6% placebo (p <0.001); no difference in mortality (NINDS trial N Engl J Med 1995;333:1581)
    • Safe + effective with expansion of administration to 4.5h of symptoms; now AHA/ASA recommendation (N Engl J Med 2008;359:1317)
    • No antithrombotics or anticoagulants for 24h after administration (Pharma­cotherapy 2010;30:493)
    • Closely monitor pts for blood pressure & neurological changes
  • UFH & LMWH
    • AHA/ASA recommend against treatment doses (Class III, level A)
    • ACCP Chest guidelines recommend for cardioembolic ischemic stroke
    • No LMWH treatment → risk of bleeding > ↓ in death or disability (Stroke 2000;31:1770)
  • ASA 325mg/d within 24 to 48h (AHA/ASA Class I, level A)
    • Do not start until 24h after alteplase
      • However, if pt took PO ASA shortly before hospital admission, not absolute CI to alteplase therapy

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Clinical Pearl 39-1

Absolute contraindications to rt-PA therapy include:

  • Evidence of intracranial hemorrhage on pretreatment evaluation
  • Suspicion of subarachnoid hemor-rhage on pretreatment evaluation
  • Recent (within 3mo) intracranial or intraspinal surgery, serious head trauma, or ...

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