Ischemic
Stroke
Presented by: Menna-Allah Sakr
Introduction
❑ Ischemic stroke: An episode of neurologic dysfunction caused by
focal cerebral, spinal, or retinal infarction.
❑ Third most common cause of death in all developed countries.
❑ Most common cause of adult disability.
Risk factors
• Age: doubles each decade after 55 years.
• Race: Risk to African Americans > Hispanics > whites
Non-
modifiable • Gender: Risks for men > women.
• Diabetes mellitus: Increases risk 1.8–6 times; risk reduction has not been shown
Somewhat for glycemic control.
modifiable
• Hypertension
• Smoking, Obesity
Modifiable • Postmenopausal hormone therapy
• Atrial fibrillation, Coronary heart disease, Peripheral artery disease.
• Asymptomatic carotid stenosis
• Patent foramen ovale
• Depression, Dyslipidemia, Pregnancy.
Primary
Prevention
I. Reduction in risk factors
E.g:
▪ Control of hypertension
▪ Smoking cessation
▪ Control of diabetes
▪ Cholesterol reduction
II. Patient Education
III. Treatment of Atrial Fibrillation
CHA2DS2-VASc is used for risk stratification:
CHA2DS2-VASc is used for risk stratification:
➢ If 0 give no therapy.
➢ If 1 give no therapy, aspirin, or oral anticoagulant.
➢ If 2 or more give oral anticoagulant.
A. Dabigatran
▪ Current guidelines suggest dabigatran over warfarin
▪ Does: 150 mg twice daily
▪ Intracranial hemorrhage was less likely with dabigatran, and GI hemorrhage was
more likely.
B. Rivaroxaban
▪ Does 20 mg/day.
▪ As effective as warfarin. Lower risk of intracranial hemorrhage and fatal bleeding
and Higher risk of GI bleeding
C. Apixaban
▪ Dose: 5 mg twice daily
▪ probably more effective than warfarin, with less risk of bleeding and mortality
D. Warfarin
▪ Probably more effective than clopidogrel plus aspirin, but intracranial bleeding
is more common.
▪ INR range 2–3
IV. Aspirin
For men: Not recommended for primary stroke prevention
For women: older than 65 years, aspirin may be used for
primary stroke prevention.
Treatment of
acute event
Tissue plasminogen
activator
Tissue plasminogen activator (Alteplase)
➢ Within 4.5 hours of symptom onset
➢ Dose 0.9 mg/kg intravenously (maximum = 90 mg) over 1 hour with
10% as a bolus.
➢ In patients not eligible for tissue plasminogen activator Initiate
aspirin (150- to 325-mg initial dose with 50- to 100-mg maintenance
dose) within 48 hours.
Tissue plasminogen activator - Exclusion criteria
▪ Intracranial or subarachnoid bleeding (or history)
▪ Other active internal bleeding
▪ Intracranial surgery, head trauma, stroke within 3 months
▪ Major surgery or serious trauma within 2 weeks
▪ Gastrointestinal or urinary tract hemorrhage within 3 weeks
▪ Blood pressure greater than 185/110 mm Hg
▪ Glucose less than 50 mg/dL or greater than 400 mg/dL
Exclusion criteria…
▪ lumbar puncture within 1 week
▪ Seizure at stroke onset
▪ Intracranial neoplasm, arteriovenous malformation, aneurysm
▪ Active treatment with warfarin (INR greater than 1.7), heparin (elevated
activated partial thromboplastin time), or platelet count less than
100,000/mm3
▪ Post-myocardial infarction pericarditis
▪ Pregnancy
Additional exclusion criteria for the 3- to 4.5-hour
period:
▪ Taking any oral anticoagulant
▪ Previous stroke combined with diabetes
▪ Age older than 80
Heparin
▪ Not recommended for stroke treatment at
therapeutic doses;
▪ Used for deep venous thrombosis prevention
Secondary
prevention
❖ Reduction in all modifiable risk factors:
▪ Hypertension: Goal less than 130/less than 80 mm Hg
▪ Hyperlipidemia: High-intensity statin therapy should be initiated or continued as first-
line therapy in women and men who have had stroke or TIA.
❖ Carotid endarterectomy:
▪ if 70%–99% stenosis.
❖ Carotid angioplasty and stenting:
▪ may be an alternative to carotid endarterectomy in some patients,
particularly younger patients.
❖ Antiplatelet therapy
❖ Anticoagulation
Antiplatelet Therapy:
▪ Clopidogrel:
Dose: 75 mg/day orally
▪ Ticlopidine:
Dose: 250 mg orally 2 times/day with food
▪ Cilostazol:
Dose: 100 mg orally twice daily on an empty stomach
Anticoagulation
Warfarin:
A. Prevention of second ischemic event, if patient has:
▪ atrial fibrillation,
▪ rheumatic mitral valve disease,
▪ mechanical prosthetic heart valves,
▪ bioprosthetic heart valves,
▪ or left ventricular mural thrombus formation
B. Target INR of 2.5 (3.0 for mechanical prosthetic heart valves)
Patient Cases
Case 1
L.R. is a 78-year-old woman who presents to the ED for symptoms of
right-sided paralysis. She states these symptoms began about 6 hours
ago and have not improved. She also has hypertension, breast cancer,
diabetes, minimal cognitive impairment, and osteoarthritis. L.R. is
diagnosed with a minor stroke by the neurology team.
Which is the most accurate list of L.R.’s risk factors for stroke?
A. Breast cancer, age, osteoarthritis.
B. Sex, diabetes, osteoarthritis.
C. Minimal cognitive impairment, diabetes, age, sex.
D. Age, diabetes, hypertension
Which best describes whether L.R. is a candidate for tissue plasminogen activator
(Alteplase) for the treatment of stroke?
A. Yes.
B. No, because of advanced age.
C. No, her stroke symptoms began too long ago.
D. No, her breast cancer is a contraindication for tissue plasminogen
activator.
L.R. previously took no home medications. Which is the best treatment currently
for her?
A. Metformin
B. Celecoxib
C. Aspirin
D. Warfarin
Case 2
L.S. is a 72-year-old woman with a medical history of hypertension, type 2
diabetes, chronic kidney disease, mitral valve replacement, and a recent transient
ischemic attack (TIA) one month ago.
She presents to the anticoagulation clinic for a follow-up visit.
Which of the following best reflects the ongoing anticoagulant management for
L.S.?
A) Warfarin to maintain target INR at 2.5.
B) Warfarin to maintain target INR at 1.5.
C) Clopidogrel 75 mg daily.
D) Direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
“Our greatest glory is not in never
falling, but in getting up every time we
fall.” – Confucius
Thank you
