Acute Stroke Therapeutics

Stroke ID & Initial Steps - Brain Attack Alert!

• Recognize Stroke: 📌 BE-FAST (Balance, Eyes, Face, Arm, Speech, Time to call).
• Immediate Actions (Pre-hospital & ED):
  • Stabilize: ABCs (Airway, Breathing, Circulation).
  • Check: Vital signs, Blood Glucose (fingerstick) - rule out mimics (e.g., < 50 mg/dL or > 400 mg/dL)!
  • History: Last Known Well (LKW) time is CRITICAL.
  • Neurological Exam: Baseline NIHSS score.
• Activate Stroke Protocol: "Brain Attack" team.
• Crucial First Imaging:
  • Non-Contrast CT Head (NCCT): STAT! Differentiates ischemic vs. hemorrhagic.

⭐ Rapid NCCT head is crucial; "Time is Brain" - every minute, ~1.9 million neurons are lost in an untreated large vessel occlusion stroke.

Ischemic Stroke - Thrombolysis & Thrombectomy Triumph

• Goal: Rapid reperfusion to salvage penumbra. 📌 "Time is Brain!"
• IV Thrombolysis (Alteplase - r-tPA):
  • Window: <4.5 hours from LSO (Last Seen Normal).
  • Dose: 0.9 mg/kg (max 90mg); 10% IV bolus, rest over 1 hr.
  • BP target pre-Rx: <185/110 mmHg.
  • Post-Rx BP target: <180/105 mmHg for 24h.
  • ⚠️ Key CIs: Persistent BP >185/110, active bleed, recent major surgery/trauma, INR >1.7, Plt <100k, Glc <50/>400.
• Mechanical Thrombectomy (MT):
  • Indication: LVO (Large Vessel Occlusion) in anterior circulation (ICA, MCA-M1/M2).
  • Window: <6 hours; up to 24 hours for select patients (DAWN/DEFUSE-3).
  • Often follows IV thrombolysis if eligible.
• Antiplatelets:
  • Aspirin (160-325 mg) at 24-48h post-stroke (or 24h post-IVT).
  • DAPT (Aspirin + Clopidogrel) for minor stroke (NIHSS ≤3-5)/TIA for 21-90 days.

⭐ The NINDS trial established IV tPA efficacy within 3 hours of ischemic stroke onset; ECASS-III extended this to 4.5 hours.

Hemorrhagic Stroke - Stop the Bleed Strategy

• Core Aims: Rapid BP control, reverse anticoagulation, manage Intracranial Pressure (ICP), neurosurgical consult.
• BP Management:
  • Target SBP <140 mmHg (if SBP 150-220 mmHg).
  • If SBP >220 mmHg, consider cautious reduction to SBP <160 mmHg.
  • Agents: Labetalol, Nicardipine, Esmolol. ⚠️ Avoid vasodilators like nitroprusside (can ↑ICP).
• Anticoagulation Reversal:
  • Warfarin: IV Vitamin K + Prothrombin Complex Concentrate (PCC) (preferred) or FFP. Target INR <1.4.
  • DOACs: Idarucizumab (Dabigatran); Andexanet alfa (Rivaroxaban, Apixaban). PCC if specific agent unavailable.
  • Heparin/LMWH: Protamine sulfate.
• ICP Control: Head elevation (30°), osmotic therapy (Mannitol, hypertonic saline), External Ventricular Drain (EVD) if hydrocephalus/significant Intraventricular Hemorrhage (IVH).
• Surgery: Hematoma evacuation for cerebellar hemorrhage >3 cm with neurological deterioration/brainstem compression, or supratentorial with significant mass effect.

⭐ For patients with intracerebral hemorrhage (ICH) on warfarin, reversal with 4-factor PCC is preferred over Fresh Frozen Plasma (FFP) due to faster International Normalized Ratio (INR) correction and lower volume administration.

Post-Stroke Care - Road to Recovery

• Supportive Care:
  • ABCs, vitals, glucose (140-180 mg/dL), temperature control.
  • Dysphagia screen, DVT prophylaxis.
  • Manage complications (edema, seizures, infection).
• Secondary Prevention (Ischemic Stroke/TIA):
  • Antiplatelets: Aspirin, Clopidogrel. DAPT (Aspirin + Clopidogrel) for 21 days (minor stroke/TIA).
  • Anticoagulation for cardioembolic source (e.g., AFib).
  • Statins: High-intensity (e.g., Atorvastatin 40-80mg) for all.
  • BP target: <130/80 mmHg (long-term).
  • Lifestyle modification.
• Rehabilitation:
  • Early physiotherapy, occupational, speech therapy.
  • Address motor, sensory, cognitive, communication deficits.

⭐ High-intensity statin (e.g., Atorvastatin 40-80mg) for all ischemic stroke patients for secondary prevention, reducing recurrence risk_._

High-Yield Points - ⚡ Biggest Takeaways

• Time is brain: Rapid reperfusion is paramount in acute stroke.
• IV Alteplase for ischemic stroke within 3-4.5 hours of symptom onset.
• Mechanical thrombectomy for LVO, window up to 24 hours in select cases.
• Immediate non-contrast CT head to exclude intracranial hemorrhage.
• BP goals: Permissive hypertension (≤185/110 mmHg) pre-thrombolysis; <180/105 mmHg post.
• Aspirin (160-325mg) within 24-48 hours (delay 24h post-Alteplase).
• NIHSS score assesses severity and guides treatment decisions.