DISEASE STATE PRESENTATION:

STROKE

Sallam Fadeyi

Clinical Seminar II

September 25, 2013

Definition

A stroke occurs when blood flow to an area of the brain is interrupted

When a stroke occurs, it kills brain cells in the immediate area

Two types of stroke:Ischemic – due to a clot (thrombus or

emboli)Hemorrhagic – caused by a ruptured blood

vessel

Prevalence

An estimated 6.8 million American ≥20 years of age have had a stroke (extrapolated to 2010 using NHANES 2007-2010 data)

Overall stroke prevalence during this period is an estimated 2.8%

2.7% of men and 2.6% of women ≥18 years of age had a history of stroke

Mortality

On average, every 4 minutes, someone dies of a stroke

Stroke accounted for approximately 1 of every 19 deaths in the United States in 2009

Stroke is the leading cause of disability and the 3rd leading cause of death in the United States

Epidemiology

Ischemic stroke – about 85% of strokes are ischemic strokes

The most common ischemic strokes include:Thrombotic stroke – occurs when a blood

clot forms in one of the arteries that supply blood to your brain

Embolic stroke – occurs when a blood clot or other debris forms away from your brain and is swept to the brain arteries

Epidemiology

Hemorrhagic Stroke – occurs when a blood vessel in your brain leaks or ruptures

The types of hemorrhagic stroke include:Intracerebral hemorrhage – a blood vessel

in the brain bursts and spills into the surrounding brain tissue

Subarachnoid hemorrhage – an artery bursts and spills into the space between the surface of your brain and your skull

Risk Factors

Stroke risk factors include:HypertensionSmokingHigh cholesterolDiabetesBeing overweight and physically inactiveCardiovascular diseaseDrinking

Pathophysiology

Signs & Symptoms

Signs and symptoms of stroke include:Sudden numbness or weakness of the face,

arm or legSudden confusion or trouble speakingSudden trouble seeingSudden trouble walking, dizziness or loss of

balanceSudden, severe headache with no cause

Diagnosis Diagnosis is based on the clinical

presentation and computed tomography (CT) scan of the head

CT scan plays a key role in determining if you’re having a stroke and what type of stroke

Sometimes, magnetic resonance imaging (MRI) may be used

An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages

PHARMACOTHERAPY

Non-Pharmacological Treatment

Lifestyle modifications include:Smoking cessationIncreased physical activity Weight reductionLimiting alcohol intakeLow fat and sodium diet

Pharmacological Treatment

Acute ischemic stroke – drug of choice is alteplase

Intracerebral hemorrhage – drug of choice is mannitol

Subarachnoid hemorrhage – drug of choice is nimodipine

Acute Ischemic Stroke

Goal of therapy is to:Maintain cerebral perfusion pressureMaintain normal intracranial pressureControl blood pressureDissolution of clot

Acute Ischemic Stroke Alteplase (Activase®, rt-

PA) 0.9 mg/kg IV over 60 min with 10% bolus

Must confirm clot in head before use

Causes fibrinolysis by binding to fibrin and converts entrapped plasminogen to plasmin

Treatment must be initiated with 3 hours of symptom onset

Contraindicated in patients with active bleed, recent surgery, severe uncontrolled hypertension

Side effects include major bleeding, hypotension and angioedema

Monitoring parameters include neurological assessments every 15 minutes and BP every 15 minutes

Acute Ischemic Stroke Antiplatelet therapy –

benefits in reduction of recurrent stroke

Aspirin 325 mg PO daily

Recommended with 24-48 hours after and not recommended within 24 hours of thrombolytic therapy

Antihypertensive – used to decrease BP gradually to prevent complications

Labetalol 10-20 mg IV over 1-2 min

Nicardipine (Cardene®) 5 mg/hr IV

Intracerebral Hemorrhage Intracerebral hemorrhage is more than

twice as common as subarachnoid hemorrhage

More likely to result in death or major disability

Vomiting is an important diagnostic sign

Intracerebral Hemorrhage Mannitol 20%

(Osmitrol®) 0.25-0.5 g/kg/dose; may repeat every 4 hours prn

Increases the osmotic pressure to reduce intracranial pressure assoicated with cerebral edema

Contraindicated in severe renal disease and severe dehydration

Side effects include fluid and electrolyte loss, dehydration

Monitor renal function, serum electrolytes, CPP, ICP and BP

Subarachnoid Hemorrhage Associated with high incidence of

delayed cerebral ischemia 2 weeks following a stroke

Vasospasm is thought to be the cause of the delayed ischemia

Subarachnoid Hemorrhage Nimodipine

(Nimotop®) 60 mg PO Q4H for 21 days

Inhibits calcium influx in vascular smooth muscle

Black Box Warning – avoid IV and other parental route (death events reported)

Side effects include hypotension, headache and diarrhea

Monitor CPP, ICP, HR, BP and neurological checks

Special Populations

Although pregnant women may be treated safely with thrombolytics, risks and benefits to mother and fetus must be carefully weighed

If patients are taking warfarin or anti-platelet drugs, transfusions of blood products may be given to counteract their effects

Pharmacist Role

Encourage compliance of medications Stress importance of non-

pharmacological factors to prevent reoccurrence of stroke

Educate patient and/or caregiver of signs and symptoms of stroke

Clinical Pearls

Alteplase is contraindicated in active bleeding and hemorrhagic stroke

Treatment should be initiated within 3 hours of symptom onset

Antiplatelet therapy is used commonly for stroke prevention Aspirin 50-325 mg dailyClopidogrel (Plavix®) 75 mg daily

References Shapiro, K., Brown, S. “Stroke” RxPrep Course

Book. RxPrep, Inc., 2013. 817-822. Print. Go AS, Mozaffarian D, Roger VL, et. al.; American

Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 2013; 127:e6–e245.

(2012, July 3). Stroke. Mayo Clinic. Retrieved September 22, 2013. http://www.mayoclinic.com/health/stroke/DS00150

Murugappan A, Coplin WM, Al-Sadat AN, et. al.; Neurology. 2006 Mar 14;66(5):768-70.

DISEASE STATE PRESENTATION:

STROKE

Sallam Fadeyi

Clinical Seminar II

September 25, 2013