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Stroke (CVA - Cerebrovascular Accidents)     Types                         
See TIA  & TIA - KP-Intranet  

  1. Acute t-PA Rx
  2. Hypertension Rx
  3. Anti-platelet agents  
  4. Anticoagulation Rx

Initial Medical Management of CVA              

1. Acute t-PA treatment within 3 hours of stroke:
A five-year clinical trial has shown that treatment with the clot-dissolving drug t-PA is an effective emergency treatment for acute ischemic stroke despite some risk from bleeding. The trial found that carefully selected stroke patients who received t-PA treatment within 3 hours of their initial stroke symptoms were at least 30 percent more likely than untreated patients to recover from their stroke with little or no disability after three months. The nationwide study of more than 600 stroke patients was organized and funded by the National Institute of Neurological Disorders and Stroke (NINDS).   Results appear in the December 14, 1995, NEJM (abstract)  See Editorial (full text)

** Guidelines from the American Heart Association & American Academy of Neurology
regarding Use of t-PA to treat Ischemic Stroke - Sep. 6, 1999 (www.Americanheart.org)

2. Blood Pressure Control.
We encourage the use of antihypertensive agents that work by peripheral action, are short acting, and are unlikely to drop the blood pressure precipitouslly .

Guideline for Treatment of Hypertension in Acute Stroke (NINDS 12/1996)    See Table       
Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke December 12-13, 1996

Algorithm for Emergency Treatment of Blood Pressure in Patients with Ischemic Stroke

  1. Blood pressure obtained by automatic sphygmomanometer should be correlated with a manual blood pressure cuff reading.
  2. If diastolic blood pressure > 140 mm Hg occurs on two readings 5 minutes apart, then start a continuous IV infusion of an antihypertensive agent such as sodium nitroprusside (0.5-1.0 mg/kg/min). Patients who fall into this category are not candidates for t-PA therapy even if other inclusion criteria are met.
  3. If systolic blood pressure is > 220 mm Hg or diastolic blood pressure is 121-140 mm Hg or mean arterial blood pressure is > 130 mm Hg on two readings 20 minutes apart, then give an easily titratable antihypertensive medication such as labetalol at 10 mg IV over 1-2 minutes. The labetalol dose may be repeated or doubled every 10-20 minutes until a cumulative dose of 300 mg has been administered via this mini-bolus technique. After the initial dosing schedule, labetalol doses may be administered every 6-8 hours as needed. Labetalol is usually avoided in patients with asthma, cardiac failure, or severe cardiac conduction abnormalities. Enalapril (1.25 mg over 5 minutes and repeated every 6 hours or as needed) is an acceptable alternative, particularly in patients with congestive heart failure. Consider starting with 0.625 mg over 5 minutes in the elderly. IV esmolol or small patches of nitropaste are other options. Patients who require more than two doses of labetalol or other antihypertensive agents to decrease blood pressure to < 185 mm Hg systolic or 110 mm Hg diastolic are generally not candidates for thrombolytic therapy even if other criteria are met.
  4. If systolic blood pressure is 185-220 mm Hg or diastolic blood pressure is 105-120 mm Hg, emergency therapy should be deferred in the absence of left ventricular failure, aortic dissection, or acute myocardial ischemia. Patients who are potential candidates for t-PA therapy but who have persistent elevations in systolic blood pressure of > 185 mm Hg or diastolic pressure of > 110 mm Hg may be treated with small doses of IV antihypertensive medication to maintain the blood pressure just below these limits. However, more than two doses of an antihypertensive agent to lower the blood pressure below these limits is a relative contraindication for thrombolytic therapy and should be discouraged.
  5. If blood pressure is lowered by antihypertensive agents in the setting of acute stroke, serial neurological examinations should be performed to look for signs of deterioration such as increasing weakness or reduced level of consciousness.
  6. In acute stroke patients with systolic blood pressure < 185 mm Hg or diastolic blood pressure < 105 mm Hg, antihypertensive therapy is usually not indicated.
  7. Although there are no data to support a threshold for treatment of hypotension in stroke patients, we recommend treatment for signs of dehydration, blood pressure that is substantially below the expected level for a given patient (consider past history of hypertension, treated or untreated), or both. Therapeutic options should include IV fluids, treatment of congestive heart failure and bradycardia, and consideration of pressor agents such as dopamine.

Treatment of hypertension in acute stroke:

3.  Anti-platelet agents     
The antiplatelet agents aspirin and ticlopidine are both beneficial in the prevention of stroke following a TIA .

The combination of aspirin and dipyridamole for stroke prevention in patients with TIA is not recommended . There is no persuasive evidence of benefit from dipyridamole (Persantine®), sulfinpyrazone, or suloctidil.

4. Treatment with heparin and warfarin is not routinely recommended for patients with TIA's
either acutely or as long-term therapy . Anticoagulation therapy is recommended for patients with TIA who have cardiac disease that is considered likely to cause embolism (atrial fibrillation, mitral stenosis, prosthetic cardiac valves, recent myocardial infarct, left ventricular thrombus, atrial myxoma, dilated cardiomyopathy, marantic (nonbacterial) endocarditis, but not for those with infective endocarditis without an underlying valvular defect . Anticoagulation therapy is an option in patients with TIA who continue to have symptoms despite antiplatelet therapy .

Intravenous heparinization of the patient with crescendo TIA is of undemonstrated benefit and without demonstrated harm. Management of the patient regarding this decision is suggested to be made on an individual basis .

Heparing and warfarin have been used to treat some cardiac conditions based on indirect evidence where the use of these medicines has not been shown to reduce TIA or stroke risk. These conditions include sick sinus syndrome, patent foramen ovale, atherosclerotic debris in thoracic aorta, spontaneous echocardiographic contrast, myocardial infarction longer than 2-6 months ago, hypokinetic or akinetic left ventricular segment, and calcification of the mitral annulus.

Treatment of Acute Ischemic Stroke - Thomas Brott, etc
NEJM Sep.7, 2000;343:710  

Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement From the National Stroke Association -  Philip B. Gorelick  
JAMA. March 24/31,1999;281:1112-1120

Clinician Information on Stroke:

Patient Information on Stroke:

       

03082000

http://www.ninds.nih.gov/disorders/stroke/stroke.htm