What is a stroke?
sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for >24h
What is Transient Ischemic Attack (TIA)?
sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for <24h (usually <30min)
What are the main modifiable risk factors for stroke?
What is the pathophysiology of ischemic stroke?
- d/t clotting
- clot blocks blood supply to brain
What are the types of ischemic stroke?
- penetrating artery disease (Lacunar)
- cardiogenic embolisms
- unknown (cryptogenic)
- Other (migraine, vasospasm, arteritis, etc)
What are the sx of ischemic stroke?
- one-sided numbness, weakness, or paralysis of face, arm, or leg
- difficultyy speaking (dysarthria) or understanding simple statements (aphasia) or confusion
- sudden blurred or decreased vision
- loss of balance or coordination/vertigo, trouble walking, or dizziness
- not usually painful, but may have a HA
- visual field defects
- altered level of consciousness
What are the general management therapies for acute ischemic stroke?
- IV fluids (no D5W)
- bolus 50% dextrose if hypoglycemic
- insulin if blood sugar >300
- thiamin 100mg if malnourished or alcoholic
- APAP if febrile
What are the drug therapies for acute ischemic stroke?
- thrombolytics (tPA):
- no hemorrhage
- < 3h from onset
- after 48h, start ASA
- no hemorrhage
- > 3h from onset
When can UH be used in ischemic stroke?
- DVT prophylaxis
- cardioembolic stroke:
- if CT scan shows no hemorrhage
- delay 24-48h (7-10d if large stroke)
- do not give bolus doses
What are the inclusion criteria for tPA?
- ischemic stroke causing measurable neurological deficit (NIH stroke score of 4-22)
- < 3h before tx
What are the exclusion criteria for tPA?
- intracranial hemorrhage on CT scan/MRI
- sx suggest subarachnoid hemorrhage
- large stroke (>1/3 hemisphere)
- rapidly improving stroke sx
- arterial puncture at a noncompressible site in last 7d
- major surgery or trauma within 14d
- GI or GU bleeding within 21d
- intracranial surgery, head trauma, MI, or stroke < 3mo ago
- previous intracranial hemorrhage
- platelets < 100,000 per mm3blood glucose < 50 or > 400 mg/dL
- BP > 185/110 mmHg despite tx
- recent anticoagulant use and elevated aPTT or INR (> 1.7)
- witnessed seizure at stroke onset
What is the recommendation for seizure tx in stroke victims?
- NO prophylactic anticonvulsants in seize-naive pts
- strongly recommend anticonvulsants to prevent recurrence once seizures have been experienced
What is the treatment for elevated intracranial pressure in a stroke pt?
- mannitol (osmotic diuresis)
How do you treat subarachnoid hemorrhagic stroke?
- triple H thrapy (HTN, hemodilution, hypervolemia) - NE or DA and IV fluids: maintains perfusion
- avoids hypotension and vasospasm
- reduces blood viscosity
- HTN may be desirable for 7-14d
- antihypertensives (nicardipine, labetalol, esmolol are DOC):
- this is to provide control without cerebral vasodilation to avoid elevating ICP
- DHP CCB
- only available orallyl
- q 4h for 21d
How do you treat intracerebral (intraparenchymal) hemorrhage?
- stop anticoag
- give vit K
- replace clotting factors (FFP or PCCs)
- Mannitol (if high ICP)
- NO steroids
- hyperventilation (failure to respond = bad prognosis)
- BP tx (compare to pre-bleed BP)
- no antiepileptics until seizure occurs
How can you help prevent ischemic stroke?
- clopidogrel (better than ASA if cost not a factor)
- aggrenox (ER dipyridamole + ASA)
- Warfarin (DOC for cardioembolic stroke (a-fib))
DO NOT combine ASA and clopidogrel
What are the rules regarding cardioembolic stroke primary prevention?
- < 65yo:
- ASA or warfarin (no risk factors)
- warfarin (at least 1 risk factors)
- > 75yo:
What are the risk factors for cardioembolic stroke?
- prior TIA, embolus, or stroke
- L ventricular dysfunction
What are the rules regarding cardioembolic stroke secondary prevention?
- If warfarin CI, give ASA
- possibly add clopidogrel to ASA
What is the pharmacist's role in stroke care?
- recognize and treat risk factors in pts
- appropriate selection of drug tx
- pt/caregiver education
- development of protocols for acute stroke