Stroke

Question 1

What is stroke?

Answer 1

Interruption of cerebral blood flow

Leads to cerebral infarction

Brain attack

Question 2

What is a transient ischaemic attack?

Answer 2

Resolves within 24 hrs (mini-stroke)

Causes:

• embolus from carotids
• atrial fibrillation

Warning for a bigger stroke

Question 3

What are the 2 different types of strokes?

Answer 3

Thromboembolic (blood clot)

• 85% of pts
• 1/4 die in the first month
• associated with cerebral artery occlusion
• hypertension - big risk factor

Haemorrhagic (bleed in the brain)

• 3/4 die in first month
• consequence of warfarin (if INR is too high)
• subarachnoid haemorrhage (e.g. aneurysm - artery bleeds out)
  
  • in younger ages
• parenchymal haemorrhage (due to hypertension)

Question 4

What types of people are at risk of stroke?

Answer 4

• Age
• Ethnicity ~ Afro-Caribbean/ Asian
• Family history
• Diabetes*
• Hypertension*
• Smoking*
• Hyperlipidaemia*
• Obesity*
• High alcohol intake*
• Certain antipsychotic drugs??

Question 5

How can you clinically identify a thromboembolic stroke?

Answer 5

Question 6

How can you clinically identify a haemorrhagic stroke?

Answer 6

Question 7

What are the clinical features of a stroke?

Answer 7

Change in consciousness

Numbness, weakness, paralysis

Altered speech

Altered co-ordination

Sudden loss of vision

• one sided
• retinal thrombosis

FAST - campaign

• F - face (fallen on one side)
• Arms (can it be raised)
• Speech (slurred)
• Time (999)

Question 8

What is a common symptom that pts complain about which could be a haemorrhagic stroke?

Answer 8

Severe headache

Explosive pain - feels like being smacked with a brick

Stiff neck

Question 9

How do we rapidly diagnose to distinguish ischaemic vs haemorrhagic?

Answer 9

Brain CT/MRI scan

Thrombolysis can be used as if it is a ischaemic (pts feel better), if it is haemorrhagic (they would feel worst)

Question 10

Comment on the evidence base for the use of atleplase in thromboembolic stroke

Answer 10

Thrombolysis with alteplase IV improves outcome if given within 4 1/2 hrs

• alteplase - tissue plasminogen activator
• thrombolytic agent = activates plasminogen which forms plasmin which chops clot up (dissolves) + leads to reperfusion (reduces cell death)

Excludes haemorrhage

300mg aspirin as antiplatelet drug immediately when they are having a stroke for 2 weeks

• PPT if they have history of dyspepsia

Question 11

How do we manage acute ischaemic stroke?

Answer 11

Do not lower BP substantially

Don’t start statins rapidly

• wait 48 hrs
• all pts (not just because of cholesterol levels)

Question 12

If there is a large clot in a large vessel, what would a radiologist do?

Answer 12

Use a catheter + wire to mechanically remove clot

Question 13

How do we prevent further (secondary) strokes)

Answer 13

Blood pressure control - <130/<80mmHg

Indapamide + perindopril

Ischaemic = clopidogrel (antiplatelet drug) 75mg OD after 2 weeks of aspirin

TIA = dipyridamole

Question 14

If the stroke is due to warfarin (atrial fibrillation) what should be done to manage it?

Answer 14

300mg aspirin for 14 days

Start warfarin 2 weeks after stroke onset

Target INR 2 - 3

Question 15

When a patient as a stroke, they cannot swallow. So what other administrations does a pharmacist need to consider?

Answer 15

Naso-gastric tubes (administer drugs in solution)

IV

Rectal route

Question 16

State some primary prevention of stroke

Answer 16

• Smoking cessation
• Blood pressure control
• Limit alcohol
• Activity ~ 30-60 min exercise 4-6 times per week
• Statins
• Detection: ultra sound of carotid
• Endarterectomy: surgical management of carotid stenosis

Question 17

What is the TARDIS + eNOS clinical trials?

Answer 17

Question 18

How do we manage a haemorrhagic stroke?

Answer 18