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Pharmacology of Ischemic Stroke Management Cheat Sheet by

Pharmacology of Ischemic Stroke Management

Physiology of Acute Stroke

Most likely involves a clot that has dislodged from a peripheral site (leg veins) and landed in a cerebral vessel (Thrombic Embolism) or perhaps a clot in situ (clot in place)
This can be very deadly.
In hemorr­hagic the blood vessel has blown out and the patient is bleeding into the brain.

Secondary Prevention of Ischemic Stroke

Antipl­atelet Therapy
Blood Pressure Management
Choles­terol Management

Antipl­atelet Therapy

Antipl­atelet therapy is recomm­ended over antico­agu­lation therapy in post ischemic stroke (unless stroke was due to Afib/C­ard­ioe­mbolic, in which warfarin of other DOAC is indicated.
Recomm­ended to start 24-48 hours post ischemic stroke. If patient was given IV alteplase, wait 24 hours after infusion to start antipl­atelet therapy.
For patients with noncar­dio­embolic ischemic stroke or TIA< aspirin 50 to 325 mg daily, clopid­ogrel 75 mg daily, or the combin­ation of aspirin 25 mg and extend­ed-­release dipyri­damole 200 mg twice daily is indicated for secondary prevention of ischemic stroke.
For high risk patients with recent minor ischemic stroke or high risk TIA, ASA + clopid­ogrel (DUAL therapy) should be initiated within 12-24 hours of symptoms onset and continued up to 90 days, followed by the contin­uation of single antipl­atelet therapy long term.
Oral antico­agu­lants for Afib patients: dabiga­tran, apixaban, rivaro­xaban, edoxaban, warfarin.

Blood Pressure Management

It is recomm­ended that a person be started on a thiazide diuretic, ACEi, or ARB
CCBs have not been shown to be effica­cious is secondary preven­tion, however they could be add ons to the above mentioned to help a patient achieve BP goals or in patients who are unable to take the first line agents.
A BP goal of < 130/80 mmHg is reasonable to help prevent secondary cardio­vas­cular events.

Choles­terol Management

Patients aged 75 years or younger are recomm­ended to be placed on a high intensity statin for secondary preven­tion.
Atorva­statin 80 mg
Rosuva­statin 20 mg (now generic, less drug intera­ctions, and less potential for myalgi­as/­ADRs)

tPA-Al­teplase (Act­iva­se)

leads to reperf­usion by clot breakdown. tPA catalyzes the conversion of plasmi­nogen to plasmin which then activates "­fib­rin­oly­sis­" which leads to clot degrad­ati­on/­dis­sol­vement
Indica­tions: who can receive this?
Patients presenting in a 3 hour time window with mild to severe stroke symptoms (the goal with best evidence is 3 hours or less, some hospitals will do up to 4.5 hours)
Patients in the 3-4.5 hour time window who are 80 yo or less, without history of diabetes or stroke, no antico­agulant use.
*It is important to try and achieve a door to needle time or no more than 60min for these patients eligible for Alteplase to increase efficacy. Brain imaging needs to be done within 20 minutes of patient arrival prior to Alteplase admini­str­ation to check for hemorr­hagic. (would make bleeding much worse)
Side Effects:
angioe­dema: stop the alteplase and ACEi if taking, start IV diphen­hyd­ramine and IV methyl­pre­dni­solone, start IV ranitidine or famoti­dine. Can also start EPI if it worsens.
Bleeding: stop alteplase, get CBC and INR, fibrin­ogen, and aPPT. Get stat head CT. Start cryopr­eci­pitate (frozen plasma rich in clotting factors) (with factor VIII) and tranexamic acid (TXA)
not after 4.5 hours (the clot becomes well organized, could become well hemorr­hagic)
not if CT shows acute intrac­ranial hemorrhage
Not if history of AIS within3 months.
CI within 3 months of severe head trauma.
CI within 3 months of major surgery.
History of intrac­ranial hemorrhage
History or signs of SAH
History of GI malignancy or bleed
Not in patients who are hyperc­oag­ulable
0.9 mg/kg (max of 90 mg)
10% given as a bolus over 1 minute
90% given as an infusion over the next 59 minutes
BP should be less than 185/110 mmHg prior to admini­str­ation to decrease chance of hemorrhage
Glucose should be >50­mg/dL before initiation




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