1. Sallam Fadeyi Clinical Seminar II September 25, 2013

2. Definition  A stroke occurs when blood flow to an area of the brain is interrupted  When a stroke occurs, it kills brain cells in the immediate area  Two types of stroke: Ischemic – due to a clot (thrombus or emboli) Hemorrhagic – caused by a ruptured blood vessel

3. Prevalence  An estimated 6.8 million American ≥20 years of age have had a stroke (extrapolated to 2010 using NHANES 2007-2010 data)  Overall stroke prevalence during this period is an estimated 2.8%  2.7% of men and 2.6% of women ≥18 years of age had a history of stroke

4. Mortality  On average, every 4 minutes, someone dies of a stroke  Stroke accounted for approximately 1 of every 19 deaths in the United States in 2009  Stroke is the leading cause of disability and the 3 rd leading cause of death in the United States

5. Epidemiology  Ischemic stroke – about 85% of strokes are ischemic strokes  The most common ischemic strokes include: Thrombotic stroke – occurs when a blood clot forms in one of the arteries that supply blood to your brain Embolic stroke – occurs when a blood clot or other debris forms away from your brain and is swept to the brain arteries

6. Epidemiology  Hemorrhagic Stroke – occurs when a blood vessel in your brain leaks or ruptures  The types of hemorrhagic stroke include: Intracerebral hemorrhage – a blood vessel in the brain bursts and spills into the surrounding brain tissue Subarachnoid hemorrhage – an artery bursts and spills into the space between the surface of your brain and your skull

7. Risk Factors  Stroke risk factors include: Hypertension Smoking High cholesterol Diabetes Being overweight and physically inactive Cardiovascular disease Drinking

8. Pathophysiology

9. Signs & Symptoms  Signs and symptoms of stroke include: Sudden numbness or weakness of the face, arm or leg Sudden confusion or trouble speaking Sudden trouble seeing Sudden trouble walking, dizziness or loss of balance Sudden, severe headache with no cause

10. Diagnosis  Diagnosis is based on the clinical presentation and computed tomography (CT) scan of the head  CT scan plays a key role in determining if you’re having a stroke and what type of stroke  Sometimes, magnetic resonance imaging (MRI) may be used  An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages

12. Non-Pharmacological Treatment  Lifestyle modifications include: Smoking cessation Increased physical activity Weight reduction Limiting alcohol intake Low fat and sodium diet

13. Pharmacological Treatment  Acute ischemic stroke – drug of choice is alteplase  Intracerebral hemorrhage – drug of choice is mannitol  Subarachnoid hemorrhage – drug of choice is nimodipine

14. Acute Ischemic Stroke  Goal of therapy is to: Maintain cerebral perfusion pressure Maintain normal intracranial pressure Control blood pressure Dissolution of clot

15. Acute Ischemic Stroke  Alteplase (Activase®, rt- PA) 0.9 mg/kg IV over 60 min with 10% bolus  Must confirm clot in head before use  Causes fibrinolysis by binding to fibrin and converts entrapped plasminogen to plasmin  Treatment must be initiated with 3 hours of symptom onset  Contraindicated in patients with active bleed, recent surgery, severe uncontrolled hypertension  Side effects include major bleeding, hypotension and angioedema  Monitoring parameters include neurological assessments every 15 minutes and BP every 15 minutes

16. Acute Ischemic Stroke  Antiplatelet therapy – benefits in reduction of recurrent stroke  Aspirin 325 mg PO daily  Recommended with 24-48 hours after and not recommended within 24 hours of thrombolytic therapy  Antihypertensive – used to decrease BP gradually to prevent complications  Labetalol 10-20 mg IV over 1-2 min  Nicardipine (Cardene®) 5 mg/hr IV

17. Intracerebral Hemorrhage  Intracerebral hemorrhage is more than twice as common as subarachnoid hemorrhage  More likely to result in death or major disability  Vomiting is an important diagnostic sign

18. Intracerebral Hemorrhage  Mannitol 20% (Osmitrol®) 0.25- 0.5 g/kg/dose; may repeat every 4 hours prn  Increases the osmotic pressure to reduce intracranial pressure assoicated with cerebral edema  Contraindicated in severe renal disease and severe dehydration  Side effects include fluid and electrolyte loss, dehydration  Monitor renal function, serum electrolytes, CPP, ICP and BP

19. Subarachnoid Hemorrhage  Associated with high incidence of delayed cerebral ischemia 2 weeks following a stroke  Vasospasm is thought to be the cause of the delayed ischemia

20. Subarachnoid Hemorrhage  Nimodipine (Nimotop®) 60 mg PO Q4H for 21 days  Inhibits calcium influx in vascular smooth muscle  Black Box Warning – avoid IV and other parental route (death events reported)  Side effects include hypotension, headache and diarrhea  Monitor CPP, ICP, HR, BP and neurological checks

21. Special Populations  Although pregnant women may be treated safely with thrombolytics, risks and benefits to mother and fetus must be carefully weighed  If patients are taking warfarin or anti- platelet drugs, transfusions of blood products may be given to counteract their effects

22. Pharmacist Role  Encourage compliance of medications  Stress importance of non- pharmacological factors to prevent reoccurrence of stroke  Educate patient and/or caregiver of signs and symptoms of stroke

23. Clinical Pearls  Alteplase is contraindicated in active bleeding and hemorrhagic stroke  Treatment should be initiated within 3 hours of symptom onset  Antiplatelet therapy is used commonly for stroke prevention Aspirin 50-325 mg daily Clopidogrel (Plavix®) 75 mg daily

24. References  Shapiro, K., Brown, S. “Stroke” RxPrep Course Book. RxPrep, Inc., 2013. 817-822. Print.  Go AS, Mozaffarian D, Roger VL, et. al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 2013; 127:e6–e245.  (2012, July 3). Stroke. Mayo Clinic. Retrieved September 22, 2013. http://www.mayoclinic.com/health/stroke/DS00150  Murugappan A, Coplin WM, Al-Sadat AN, et. al.; Neurology. 2006 Mar 14;66(5):768-70.

25. Sallam Fadeyi Clinical Seminar II September 25, 2013