STROKE AND DVT

Question 1

What are the different types of stroke

Answer 1

ischemic stroke - TIA (transient ischemic attack)-
Cerebral infarction-
Hemorrhagic stroke-

Question 2

what are the treatment option for treating ischemic stroke

Answer 2

PHARMACOLOGICAL TREATMENT

1. SK,
   APSAC-
   rt-PA-Tissue plasminogen activator
2. Alteplase -
   LD: (10% of total dose, 0.9mg/kg) over 1min then 90%
   over 1hr-
3. –ASA - 180-325 mg after altepase

secondary prevention

4. ASA 25 mg and Dipyridamole 200mg bd
5. warfarin / dabigatran if the source of embolism is from the heart

STATINS- regardless of base line cholesterol

7 . LMWH or LDUH 5000 units /day recommended for prophylaxis of DVT.

8. ASA - 180-325 mg and Clopiidogril 75 mg after completion of alteplase

NON PHARMACOLOGICAL TREATMENT

SURGERY-

1. Carotid endarterectomy
   incision along the front of your neck, opens your carotid artery and removes the plaques that are clogging your artery.

Indications- TIAs and mild completed stroke

2 . Stenting

Question 3

what is the Approach in the management of ischemic Stroke

Answer 3

1. the patient has to be eligible for treatment with
   intravenous rtPA or other acute reperfusion intervention.

2 if the BP is Systolic >185 mm Hg or diastolic
>110 mm Hg give :

a. Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat x1;

 or Nitropaste 1 to 2 inches

 or Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to
 15-minute intervals, maximum dose 15 mg/h;

3. Control glucose level if ;
   > >10 mmol/L (>about 200 mg/dL).-IV or subcutaneous
   insulinIf blood pressure does not decline and remains >185/110
   mm Hg, do not administer rtPA

Question 4

how do you manage blood pressure during and after treatment with rtPA or other acute reperfusion intervention

Answer 4

if Systolic 180 to >230 mm Hg or diastolic 105 to 140 mm Hg

give Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20 minutes,

Question 5

what are some of the additional stroke care that is needed.

Answer 5

1. oxygenation and ventilation,
2. nutritional support.

3 .normal saline

4. treatment of acute seizures
5. Monitor for intracranial
   pressure.

Question 6

What are the three main Inclusion Criteria that must be met before initiating rTPA ?

Answer 6

1. Age 18 years or older?
2. Clinical diagnosis of ischemic stroke with a
   measurable neurologic deficit?
3. Time of symptom onset (when patient was last
   seen normal) well established as <180 minutes (3
   hours) before treatment would begin?

Question 7

What are the three main exclusive Criteria that must be met before initiating rTPA ?

Answer 7

1. Evidence or history of intracranial hemorrhage
2. Uncontrolled hypertension:
3. Witnessed seizure at stroke onset?
4. Heparin received within 48 hours,
   5.—Current use of anticoagulant (eg, warfarin sodium) that
   has produced an elevated international normalized ratio
   (INR) >1.7 or prothrombin time (PT) >15 seconds?* Within
   3 months of intracranial or intraspinal surgery, serious
   head trauma, or previous stroke?

Question 8

how do you manage seizures in HEMORRHAGIC stroke.

Answer 8

Diazepam 5 mg IV q5-10min + phenytoin or phenobarbital.

Question 9

what are the treatment options for HEMORRHAGIC stroke

Answer 9

Surgery

Corticosteroids e.g. dexamethasone-

Mannitol- reduce edema -Dose: 0.25- 2g/kg IV q4-8 until serum osmolality raised to 300- 310 mosm/L

Recombinant activated factor VII (rFVIIa)

Question 10

What is the MOA for dipyridamole and side effects

Answer 10

it inhibits Phosphodiesterase PDE which is responsible for the break down of cAMP to AMP which is responsible for platelets activation – no platelets activation no platelets sticking no clot

May cause vasodilation because it prevent the brake down of cGMP which is responsible for vasodilation’ resulting in headache.