What is Stroke?

Stroke is a disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a leading cause of disability in the United States.

A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens , part of the brain cannot get the blood (and oxygen) it needs, so it and brain cells die.

The MAJOR treatable risk factors for Ischemic:

– HTN,
– Diabetes Mellitus,
– Smoking,
– Dyslipidemia

Hypertension is a risk for ‘atherosclerotic disease’ & is the most important modifiable risk for stroke. Current recommendation is a SBP goal of <150mmHg & DBP goal of <90mmHg in patients >60 year old.

Ischemic Stroke [Embolic stroke & Thrombotic stroke]

– Thrombolytics [e.g. activase] – is initial therapy, provided that treatment is initiated within 3-4.5 hours of clearly defined symptom onset.
– Aspirin [full dose 325mg] – Initial therapy for those who come in too late for thrombolytics. Also indicated AFTER the use of thrombolytics.
– Start clopidogrel [Plavix] – Switch to clopidogrel if patient developed stroke while on aspirin or patient does not tolerate aspirin [eg. Allergic or gastritis]
– Start dipyridamole [Persantine]– If patient is already on aspirin when a New stroke or TIA occurs. Add dipyridamole or switch to clopidogrel.
– Statin therapy – For patients with acute ischemic stroke. Start or continue statin treatment as soon as oral medications can be used safely regardless of their cholesterol status.
– Strict BP managed to keep it <185/105 mmHg but >140/90 mmHg to maintain cerebral perfusion & avoid hemorrhagic transformation. Treat HTN with ‘IV’ labetalol, nicardipine or nitroprusside.

In ischemic stroke (embolic stroke & thrombotic stroke), everyone must get:

– Non-contrast CT to rule out Hemorrhagic stroke
– Give a full dose Aspirin (325mg) right after the CT of head rules out hemorrhagic stroke. (Do not give any Aspirin or thrombolytics before obtaining head CT)
– EKG [look for a-fib],
– TTE or TEE to look for Thrombus, PFO, ASD, VSD. TEE is more sensitive but more invasive, so TTE is done more often than TEE.
– CT Angiogram or MR Angiogram may be obtained to evaluate intracranial vasculature or Duplex Ultrasound to evaluate carotids ‘Alone’.
– Non-contrast MRI can be done to Confirm ischemic stroke but not necessary.

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