Stroke Treatment and Diagnosis Overview

Stroke Treatment Stages

• Prevention: Controlling blood pressure, managing cholesterol and saturated fat intake, avoiding smoking, managing diabetes, maintaining a healthy weight, and regular exercise
• Acute Care: Diagnosing stroke type and cause, maintaining cerebral blood flow, minimizing brain injury, and maximizing recovery
• Rehabilitation: Specialized therapies for recovery, including physical therapy, occupational therapy, and speech and language therapy

Stroke Diagnosis

• Clinical Assessment: Observation, complete history, head-to-toe physical examination, including a comprehensive neurological examination
• National Institutes of Health (NIH) Stroke Scale: Assesses neurological outcome and recovery, focusing on LOC, vision, facial paralysis, motor abilities, ataxia, sensation, language, and attention
• Imaging: Identifies increased stroke risk and pathophysiologic changes after a stroke
  • CT Scans: Demonstrates hemorrhage, aneurysm, ischemia, edema, tumors, and tissue necrosis, differentiates stroke types
  • Cerebral Arteriography, MRI, Magnetic Resonance Angiography, Transcranial DUS, PET, and Single-Photon Emission CT: Additional diagnostic tools
• Blood Test: New test screens for recurrent stroke risk by detecting high levels of lipoprotein-associated phospholipase

Stroke Pharmacological Therapy

• Prevention: Medications based on patient history, including antiplatelet/anticoagulant agents, antihypertensives, and cholesterol-lowering drugs
  • Antiplatelet Agents: Aspirin and clopidogrel (Plavix), reduce clot formation and vessel occlusion
  • Anticoagulants: Warfarin (Coumadin, Jantoven), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and dabigatran (Pradaxa), prevent clot formation in the heart
  • Antihypertensives: Thiazide diuretics, CCBs, ACE inhibitors, and ARBs, manage high blood pressure
  • Cholesterol-Lowering Drugs: Statins (atorvastatin, lovastatin, simvastatin) and fibric acid agents (fenofibrate and fenofibric acid)
• Acute Stroke: Anticoagulants, platelet inhibitors, and thrombolytic agents manage thrombotic stroke
  • Thrombolytic Therapy: Recombinant tissue plasminogen activator alteplase (rt-PA, tPA), converts plasminogen to plasmin to dissolve clots
  • tPA Administration: Most effective within 3 hours after symptom onset, up to 4.5 hours for specific patient groups
  • tPA Contraindications: Age over 80, history of diabetes and prior stroke, aspirin may be an alternative
  • Anticoagulants/Antiplatelet Therapy: Used to prevent further clot formation and extension

Stroke Surgical Management

• Carotid Endarterectomy: Removes atherosclerotic plaque from the carotid artery bifurcation to prevent stroke
• Extracranial-Intracranial Bypass: Reestablishes blood flow in occluded or stenotic vessels not amenable to radiologic clearance
• Carotid Angioplasty with Stenting: Treats cerebral stenosis

Inflammation

• Adaptive Response: Brings fluids, dissolved substances, and blood cells to the site of injury or illness
• Nonspecific Response: Identical events regardless of the cause
• Neutralization and Elimination: Removes the invader, destroys tissue, and initiates healing
• First Phase of Healing: Following tissue injury or infection
• Agents Causing Inflammation: Microorganisms (bacteria, viruses, fungi, helminths, protozoans), chemical agents (internal or external), and physical agents (trauma, heat, cold, radiation)
• Disorders: Denote with suffix '-itis' (e.g., bronchitis, colitis, gastritis)
• Manifestations: Erythema (redness), heat, swelling (edema), pain, and potential impaired function

The Inflammatory Process

• Complex Vascular Response: Triggered by harmful stimuli
• Protection: Isolates damaged area and promotes surrounding tissue repair
• Classification: Acute or chronic
• Acute Inflammation: Quick response within minutes to hours of injury
• Chronic Inflammation: Persistent response for months or years, can follow acute inflammation but not always

Stages of Inflammation

• Vascular and Cellular Responses: Immediate vascular constriction, release of histamine, kinins, and prostaglandins, resulting in vasodilation, hyperemia (increased blood flow), and erythema (redness), increased vascular permeability, edema (swelling), and pain
• Exudate Production: Fluid, proteins, and leukocytes leak into interstitial spaces
• Reparative Phase: Tissue healing and repair

Inflammation Phases

• The inflammatory response has three phases: adhesion/transmigration, exudate production, and reparative phase.
• Adhesion: Leukocytes attach to receptors on endothelial cells.
• Transmigration: Leukocytes squeeze through the cell lining and enter the wound site.
• Leukocytosis: The bone marrow increases leukocyte production and releases them into the blood.
• Exudate Production: Inflammatory exudate leaks from blood vessels and contains fluid, cytokines, histamines, dead cells, and injured tissue cells.
• Types of Exudate:
  • Serous: Clear or straw-colored, associated with mild inflammation.
  • Purulent: Contains leukocytes, other cells, and debris, indicating infection.
  • Hemorrhagic: Contains blood from ruptured vessels, red and thick.
• Reparative Phase: The body shifts from inflammation to repair.
  • Regeneration: Damaged cells are replaced with identical or similar cells.
  • Fibrous (scar) tissue formation: Occurs when regeneration is not possible.
  • Granulation tissue: Fragile, gelatinous tissue with new capillaries.
  • Cicatrix (scar tissue): Firm fibrous tissue formed from contracted collagen fibers.

Mediators of Inflammation

• Mast cells: Found in many tissues and release mediators like histamine and heparin.
• Histamine: Causes vasodilation and increased permeability, attracting eosinophils.
• Heparin: Prevents blood clotting.
• Complement: A system of proteins that contribute to various aspects of inflammation, including dilation, permeability, chemotaxis, phagocytosis, and histamine release.
• Leukotrienes: Attract neutrophils and macrophages.
• Prostaglandins: Cause vasodilation.
• Anaphylaxis: A life-threatening allergic reaction with a rapid release of inflammatory mediators.
• Triggers of Anaphylaxis:
  • Foods (peanuts, shellfish, milk, eggs)
  • Insect stings
  • Medications (penicillin, anesthetics, NSAIDs)
  • Latex
• Epinephrine (adrenaline): First-line treatment for anaphylaxis, dilates bronchi, constricts blood vessels, and counteracts the negative effects of the allergic response.
• Antihistamines: Block histamine receptors, reducing allergic symptoms.

This quiz covers the essential stages of stroke treatment, including prevention, acute care, and rehabilitation strategies. Additionally, it explores the various methods for diagnosing stroke, such as clinical assessments and imaging techniques. Test your knowledge on the vital aspects of stroke management and recovery.