Ischemic vs Hemorrhagic StrokeIschemic vs. Hemorrhagic Stroke
Rihab Kaissi, BSc(Pharm)Doctor of Pharmacy Student
College of PharmacyCollege of Pharmacy Qatar University
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OutlinesOutlines
• DefinitionDefinition• Stroke types• EpidemiologyEpidemiology• Risk Factors• Clinical Presentations• Clinical Presentations• Diagnosis• Treatments• Treatments• Prognosis
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DefinitionsDefinitions
• StrokeStroke– is an abrupt‐onset focal neurologic deficit that lasts at least 24 hours and is of presumed vascular origin
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Etiology and Classification of StrokeEtiology and Classification of Stroke
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke• Large‐artery atherosclerotic
infarction
Hemorrhagic Stroke• Subarachnoid hemorrhage• Intracerebral hemorrhage
• Embolism from a cardiac source
ll l d
Intracerebral hemorrhage• Subdural hematomas
• Small‐vessel disease• Other determined cause
– Dissection hypercoagulableDissection, hypercoagulablestates, or sickle cell disease; and infarcts of undetermined cause
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Etiology and Classification of StrokeEtiology and Classification of Stroke
• Subarachnoid hemorrhageSubarachnoid hemorrhage– Occurs when blood enters the subarachnoid space, owing to either trauma, rupture of an intracranial aneurysm, or rupture of an arteriovenous malformation
• Intracerebral hemorrhageh bl d l i hi h b i– Occurs when a blood vessel ruptures within the brain
parenchyma itself
• Subdural hematomas• Subdural hematomas– Collections of blood below the dura and they are caused most often by trauma
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EpidemiologyEpidemiology
• Stroke occurs in more than 700,000 individuals perStroke occurs in more than 700,000 individuals per year and results in 150,000 deaths
• Currently 4.6 million stroke survivors in the USy• One quarter of the 795 000 strokes that occur each year are recurrent eventsy– Ischemic, 88%– Hemorrhagic, 12%
• The stroke has an annual costs greater than $50 billion
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EpidemiologyEpidemiology
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Risk FactorsRisk Factors
Nonmodifiable Modifiable Potentially modifiable
•Age•Gender•RaceF il hi t f t k
•Hypertension **•Atrial fibrillation•DiabetesD li id i
•Oral contraceptives•Migraine•Drug and alcohol abuseH t ti d•Family history of stroke
•Low birth weight•Dyslipidemia•Cigarette smoking**•Alcohol**•Sickle cell disease
•Hemostatic and inflammatory factors•Sleep disordered breathing
•Asymptomatic carotid stenosis•Postmenopausal hormone therapy
g
therapy•Lifestyle factors•Cocaine use **
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Clinical PresentationClinical Presentation
• SymptomsSymptoms– Weakness on one side of the body– Inability to speak– Loss of vision– Vertigo/falling
** Ischemic stroke is not usually painful, but patients may complain of headache, and with hemorrhagic stroke, it can be very severe
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Clinical PresentationClinical Presentation
• SignsSigns– Multiple signs of neurologic dysfunction– Hemi‐ or monoparesis occurs commonly
d d bl l k l h l– Vertigo and double vision are likely to have posterior circulation involvement
– Aphasia and anterior circulation strokes– Dysarthria, visual field defects, and altered levels of consciousness
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DiagnosisDiagnosis
• Patient clinical assessmentPatient clinical assessment– ABCs, Stroke rating scale (NIHSS)
• Brain Imaging g g– CT scan – MRI head scan
• Cardiac tests (ECG)
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Goals of TherapyGoals of Therapy
• To reduce the ongoing neurologic injuryTo reduce the ongoing neurologic injury• Decrease mortality and long‐term disability• Prevent complications secondary to immobility andPrevent complications secondary to immobility and neurologic dysfunction
• Prevent stroke recurrencePrevent stroke recurrence
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Initial General AssessmentInitial General Assessment
• Airway and breathingAirway and breathing– Patients with increased ICP (intracranial pressure) due to hemorrhage or ischemia may have decreased respiratory drive
• Intubation is necessary to restore adequate ventilation and to protect against aspiration
– Patients with adequate ventilation should have O2 saturation monitored
If h i O2 i i• If hypoxic, O2 is given
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Initial General AssessmentInitial General Assessment
• Head PositionHead Position
Ischemic Stroke Hemorrhagic Stroke
•Flat as possible in bed for at •Should be maintained•Flat as possible in bed for atleast the first 24 hours from stroke onset•Ideally with head‐of‐bed
•Should be maintainedat 30°in bed
between 0°and 15°
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Initial General AssessmentInitial General Assessment
Hypertension Ischemic Stroke Hemorrhagic Management Stroke
Indication SBP>220 mmHg or DBP>120
)
SBP >200 mmHg or MAP >150
mmHg) or the patient has:1. Active ischemic2. coronary
mmHg
•Aggressive reduction of BP2. coronary
disease3. Heart failure4. Aortic
di ti
reduction of BP with continuous IV medications
dissection5. Hypertensive
nephropathy6. Pre‐
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eclampsia/Eclampsia
Initial General AssessmentInitial General Assessment
Hypertension Ischemic Stroke Hemorrhagic Management Stroke
Indication SBP>220 mmHg or DBP>120
)
SBP >180 mmHg or MAP >130 mmHg
mmHg) or the patient has:1. Active ischemic2. coronary
and evidence orsuspicion of elevated ICP
2. coronary disease
3. Heart failure4. Aortic
di ti
•Monitoring ICP and reducing BPusing intermittent
ti IVdissection5. Hypertensive
nephropathy6. Pre‐
or continuous IV medication to keep cerebral perfusionpressure in the
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eclampsia/Eclampsia
prange of 61 to80 mmHg
Initial General AssessmentInitial General Assessment
Hypertension Ischemic Stroke Hemorrhagic Management Stroke
Indication SBP>220 mmHg or DBP>120
)
SBP >180 mmHg or MAP >130
mmHg) or the patient has:1. Active ischemic2. coronary
mmHg and no evidence orsuspicion of elevated ICP2. coronary
disease3. Heart failure4. Aortic
di ti
elevated ICP
• Modest reduction of BP usingi t itt tdissection
5. Hypertensive nephropathy
6. Pre‐
intermittent or continuous IVmedication, andreexamine the
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eclampsia/Eclampsia
patient every 15Minutes
Initial General AssessmentInitial General Assessment
Hypertension Ischemic Stroke Hemorrhagic Management Stroke
Drugs First Line 1. Labetalol
• Labetalol, nicardipine,
2. transdermalnitroglycerin
3. IV Nicardipine
esmolol, enalapril,hydralazine, nitroprusside, and nitroglycerine can
Second line1. Nitroprusside
nitroglycerine can be used
• Nimodipine is d i SAH tused in SAH to
prevent vasospasm: dose is 60 mg every 4 hours PO
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TreatmentsTreatments
• Non PharmacologicalNon Pharmacological
Ischemic Stroke Hemorrhagic Stroke
1 Craniectomy 1 Clip/ ablate the vascular1. Craniectomy2. Carotid endarterectomy
1. Clip/ ablate the vascular abnormality
2. Endovascular therapy 3. Craniotomy
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TreatmentsTreatments
• PharmacologicalPharmacological
Ischemic Stroke Hemorrhagic Stroke
1 Intravenous thrombolytic 1 Drugs to reduce ICP1. Intravenous thrombolytic therapy
2. Antiplatelet therapy3. Antithrombotic therapy
1. Drugs to reduce ICP2. Antithrombotic therapy3. Antiepileptic
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TreatmentTreatment
• IV rtPA (0.9 mg/kg, maximum dose 90 mg) isIV rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke
Ischemic Stroke Hemorrhagic Stroke
Inclusion Criteria
1. Age 18 years or older2. Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit
Not applicable
measurable neurologic deficit3. Time of symptom onset well established to be < 180 minutes
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TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Exclusion Criteria
1. Evidence of ICH on non‐contrast head CT
Not applicable CT
2. Minor or rapidly improving stroke symptoms
3. High clinical suspicion of SAH even g pwith normal CT
4. Active internal bleeding 5. Known bleeding diathesis, platelet
count <100 000/mm3count <100,000/mm36. Patient has received heparin within 48
hours and had an elevated APTT7. Recent use of anticoagulant and
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elevated PT (>15 second)/INR
TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Exclusion Criteria
7. Intracranial surgery, serious head trauma or previous stroke within 3
Not applicabletrauma, or previous stroke within 3 months8. Major surgery or serious trauma
within 14 days9. Recent arterial puncture at
noncompressible site10. Lumbar puncture within 7 days11 History of intracranial hemorrhage11. History of intracranial hemorrhage, arteriovenous malformation, or aneurysm12. Witnessed seizure at stroke onset13. Recent acute myocardial infarction
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14. SBP >185 mm Hg or DBP >110 mm Hg at time of treatment
TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Intracranial Pressure Control
Not applicable 1. Sedation and analgesia by IV Midazolam or Etomidate or Propofolp
2. IV Mannitol3. Barbiturate anesthesia4. Hyperventilation5 N l5. Neuromuscular
blockade
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TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Neuro protection Cooling the ischemic brain (intravascular coils versus surface cooling) and
Lorazepam or Diazepam followed directly by IV Phenytoin and g)
rewarming the patient after hypothermia
yFosphenytoin
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TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Antiplatelet Therapy Early aspirin therapy (initial dose 325 mg, thereafter 150 to 325 mg/day) should
Not applicable
g/ y)be given to patients who are not receiving alteplase, IV heparin, or oral ti l tanticoagulants
In case of ASA tolerance, clopidogrel or ticlopidinecan be given
ASA can be given 24‐48 hours after alteplase
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hours after alteplase
TreatmentTreatment
Ischemic Stroke Hemorrhagic StrokeIschemic Stroke Hemorrhagic Stroke
Anticoagulant Therapy Offered in patients with stroke due: • Cardioembolism from
All anticoagulant and antiplatelet drugsshould be D/C acutely for
intracardiac thrombus associated with valvulardisease, severe CHF, or
h i l h t l
/ yat least 1‐2 weeksafter the onset of hemorrhage
mechanical heart valves• Large artery atherosclerotic stenosiswith intraluminal thrombus
Anticoagulants may be considered after the cessation of bleeding in
•Dissection of a cervical or intracranial large artery
patients with hemiplagiaafter 3 to 4 days from onset
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MonitoringMonitoring
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PrognosisPrognosis
• Mortality rates are decliningMortality rates are declining• Over 75% of patients survive a first stroke during the first yeary
• Over half survive beyond 5 years
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ReferencesReferences
• Adams HP et al. Guidelines for the EarlyAdams HP et al. Guidelines for the Early Management of Adults With Ischemic Stroke: Stroke 2007; 38:1655‐1711
• Broderick J et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 update: Stroke 2007; 38:2001‐2023
• Dipiro JT et al. Pharmacotherapy: A pathophysiologich th dapproach. 7th edition. 2008
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