Stroke Treatment and Management

Study Notes

Stabilize the patient's general condition
Give therapy directed at specific aspects of stroke pathogenesis
Treat complications
Initiate early secondary prevention measures to reduce incidence of stroke recurrence
Begin rehabilitation measures

Thrombolysis with recombinant tissue plasminogen activator (rt-PA) using alteplase
Given within 3-4.5 hours from the onset of symptoms (golden time window)
Inclusion criteria: symptoms suggestive of ischemic stroke, able to initiate treatment within 4.5 hours, age 18 years or older
Contraindications: intracranial hemorrhage, brain CT demonstrates large infarction, elevated blood pressure, recent head trauma or neurosurgical operation, INR > 1.7, thrombocytopenia, recent use of heparin or direct oral anticoagulants, intracranial neoplasm, or aneurysm, active internal bleeding

Thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis
Indications: large artery occlusion in anterior cerebral circulation

Warfarin (Marevan): indicated in hypercoagulable states, cardiac sources like AF or intracardiac thrombi
Dabigatran (Pradaxa): indicated in persistent or paroxysmal non-valvular AF
Rivaroxaban (Xarelto): factor Xa inhibitor, reduces the risk of stroke and systemic embolism in non-valvular AF

Anti-hypertensive drugs if BP is above 200/120 mm Hg, with very gradual reduction
Avoid sudden marked reduction of BP, which decreases cerebral blood flow and worsens brain ischemia

Statins and cholesterol-lowering agents: shown to lower the risk of atherosclerotic mortality and vascular events, including stroke
Smoking cessation, DM control, a low-fat low-salt diet, weight loss, and regular exercise

Piracetam (Nootropil): improves brain metabolism by increasing O2 consumption
Pentoxifylline (Trental): improves the microcirculation of the brain by increasing RBCs deformability and reducing platelet aggregation