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Clinical Presentation and Diagnosis of Stroke
The map starts with the warning signs of stroke which result from sudden loss of blood circulation to an area of the brain. Once the patient reaches the emergency department, diagnostic procedures are done to exclude other causes of neurologic deficit and to establish the type of stroke whether it is ischemic or hemorrhagic. An essential part of diagnosis is to identify the time of onset of stroke, for deciding if the patient is eligible for thrombolytic therapy. And to identify the risk factors in order to determine secondary preventive measures.
Pathophysiology and Risk Factors
Ischemic stroke is caused mainly by cerebral artery occlusion, which occurs due to one of the following three mechanisms, either, thrombotic occlusion, embolism, or systemic hypoperfusion. You’ll find links between the modifiable risk factors and these mechanisms. For example, atherosclerosis as a risk factor for ischemic stroke may cause atherosclerotic thrombosis or embolism which leads to cerebral artery occlusion. Modifiable risk factors of stroke should be considered for primary as well as secondary prevention of Ischemic stroke.
Treatment and Secondary Prevention
Treatment of ischemic stroke includes supportive care, pharmacological treatment, and nonpharmacological treatment.
Regarding pharmacological treatment, it includes mainly, thrombolysis using the fibrinolytic agent alteplase, then antithrombotic therapy using tnti-platelet drugs and anticoagulants.
For patients with acute stroke without cerebral venous sinus thrombosis who are presented within 4.5 hours and have no contraindication to thrombolysis, alteplase is the first choice. However, for those who are presented after 4.5 hours or have contraindications to thrombolysis, aspirin is the first choice therapy.
And for acute stroke with cerebral venous sinus thrombosis, full-dose anticoagulation treatment with heparin then warfarin is recommended.
Antithrombotic therapy also plays a role in the secondary prevention of ischemic stroke. In the case of Noncardioembolic stroke or transient ischemic attack (TIA), antiplatelet therapy is recommended for secondary prevention. But in the case of cardioembolic stroke, warfarin is used instead.
Low-dose subcutaneous unfractionated or low molecular weight heparin has a role in prophylaxis against deep pain thrombosis and pulmonary embolism that usually threaten immobilized stroke patients. Anticoagulants should be used with high consideration to the potential risk of bleeding as an adverse effect of these agents.
Non pharmacological therapy including Carotid Endarterectomy or Carotid Angioplasty and Stenting is considered for secondary prevention for selected patients with carotid artery stenosis.
Back to alteplase for further details. Alteplase is a fibrinolytic agent that causes the breakdown of a blood clot and restoration of blood supply to the brain, resulting in the resolution of neurologic deficits. However, the hyperfibrinolysis effect of alteplase may cause hemorrhage which is manifested as systemic hemorrhage or intracranial hemorrhage. Accordingly, an ischemic stroke patient should be monitored for the signs of hemorrhage and managed as needed. The patient should also undergo neurological assessment, blood pressure measurement, and computed tomography (CT) scanning in case of suspected hemorrhage and 24 hours before starting anticoagulants or antiplatelet agents, in order to avoid the risk of bleeding.
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