Ischemic vs Hemorrhagic Stroke - Qatar...

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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• 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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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




)

SBP >180 mmHg or MAP >130 mmHg


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




)

SBP >180 mmHg or MAP >130


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



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


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


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


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


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


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


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


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


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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