Now, what about the treatment
for ischemic stroke?
Well, in ABCs, you always want
to make sure that you’re able
to take care of the airway, the
breathing, and circulation.
That’s always going to be
the issue with stroke.
Now, with your blood pressure control,
you want to keep in mind
with systolic blood pressure
between, let’s say, 180 and 220.
And then if it’s a
diastolic blood pressure,
you may be approximately
140 to about 120.
You want to be less than that
so that you’re able to manage your
patient who has suffered a stroke.
Antiplatelet therapy, aspirin.
Anticoagulation. If, if, the
patient luckily is the hospital,
heparin has to be instituted
and helps and hurts, only used
in atrial fib and dissection.
So be careful.
If your patient is already
in a state of vulnerability,
is already in the state of maybe bleeding,
and if your patient is not suffering
from atrial fibrillation or dissection,
then be really careful
It’s rapidly acting, works
through antithrombin III.
And it might actually hurt the patient,
may result in a hemorrhagic stroke,
so be careful with heparin, please.
I’m going to walk
you through tPA,
very, very important.
And I want to walk you through this.
I’m going to walk you through a great
detail as to the contraindications for TPA
that you must know
for your boards.
And then rehab.
I promised you that we’d
come back to the indications
for tissue plasminogen
Remember that the physiology behind
your tPA is the fact that plasmin
is an “enzyme” that breaks down your
fibrin clot very, very quickly.
In other words, it’s a thrombolytic agent
physiologically or homeostatically.
And of course, we used
this to our advantage
in which we can then try to break
down our clot very quickly.
And we have discussed this earlier
with myocardial infarction.
And earlier, we talked about
streptokinase, alteplase, your -ase drugs.
You’re worried about
Now, here with tPA, remember now
we’re trying to break down a clot
that may then be resulting
in ischemic stroke.
So the indications kind of
seem similar, don’t they?
a huge but,
are going to be the list of contraindications
that I’m about to give you.
The criteria is pretty
Clinical diagnosis of
ischemic stroke for all
the different reasons
we’ve talked about.
Your patient has to be older,
greater than 18.
Now, here, this is important.
Time to tPA administration, less than three
hours from the onset of the symptoms.
So this is where your imaging studies
are going to become incredibly crucial.
Granted in current day practice,
there are many, many advancements
in imaging and such.
But at this point, something that I
walked you through is the noncontrast CT
and where, for example, I gave you
middle cerebral artery type of stroke
and what it means from one hour.
And the more hyperdense you
become, which means what?
Then more time has lapsed.
So really pay attention to
three hours, please, with tPA.
Now, the head CT, without contrast,
things that you want to
make sure that you identify
is has there been a hemorrhage?
What about the size of the stroke?
And if that size of the stroke is rather
large and there’s a lot of hyperdense area
on that head CT,
then you want to start maybe questioning
whether or not you want to use your tPA.
Or if there’s hemorrhage
Remember, tPA is already going
to break down the clots.
So you’re already increasing the
risk of hemorrhage taking place.
And if you indentify
evidence for a hemorrhage,
then you really want to
be careful by using tPA.
Now, let’s walk into the all
There’s a large list here
and I’d recommend that you spend some
time making sure that you know these.
Now, clinical judgement of using tPA
is different from doctor to doctor,
neurosurgeons, so on and so forth.
But what I can speak to you
about is going to be the facts
of when it’s
contraindicated to use tPA
and these you want to make sure
that you commit to memory.
Stroke or serious head trauma
in the last three months.
Once again, you want to worry about
hematomas that are taking place.
Remember, whenever there is a trauma
that’s taking place with the head,
they could be multiple
causes as we shall see.
History of intracranial
hemorrhage or AV malformations.
If there’s already a history of
bleeding taking place in your patient,
then you want to make sure that you
avoid tissue plasminogen activator.
This is a list of contraindications.
The list prior was a list of criteria
in the past six weeks.
Be careful. Contraindicated to use tPA.
Major surgery or trauma
in the last two weeks.
GI or urinary tract hemorrhage
in the last three weeks.
So you want to make sure that you
evaluate your patient for hemorrhage
up and down the body because
you’re never quite sure
as to how vulnerable your
patient is to hemorrhage
because you’re worried about the potency
of tPA because it is extremely effective.
Lumbar puncture or your arterial puncture
at non-compressible site in the last week,
tPA will be contraindicated.
And aggressive blood pressure therapy is
absolutely required prior to using tPA.
And if that blood pressure,
we talked about indications
for systolic and diastolic blood pressure,
and if that is not controlled,
then please make sure that tPA is
carefully, if at all, administered.
Continuing our discussion,
if there’s elevated PT,
let’s say above 15 seconds
or above 40 seconds for PTT,
Platelet count. if there
isn’t enough platelets,
you start dropping down below
100,000s, specifically 50,000,
And glucose, either
hypo or hyperglycemic,
less than 40, greater than
400, give yourself a range.
Pregnancy, tPA contraindicated.
There is something called the NIH scale
and remember that scale that I
walked you through just a little bit
and I told you, "Get an idea."
If it’s less than 4 or greater than
22, then tPA will be contraindicated.
If your patient is
recovering from the stroke,
then you probably don’t want
to give tPA at this point.
You monitor your
patient very closely.
And then seizure at onset.
Oftentimes and we’ll talk about this later
on when we talk about seizures and epilepsy
and when we do, whenever there
is seizure type of symptoms,
then you try to
avoid tPA, please.
Secondary preventions, so at this point,
we’ve closed our discussion of tPA.
We’ve talked about the criteria
and more importantly, we’ve walked through
some very important contraindications.
Let’s do secondary prevention.
Antiplatelet agent, aspirin or
you’ve heard of clopidogrel.
It’s your ADP inhibitor
from your platelet
so that you do not express
your glycoprotein IIb/IIIa.
And you probably know this as a generic –
Your trade name is Plavix
or there’s another one called Aggrenox,
and that is your dipyridamole.
These are antiplatelet agents.
Once again, remember, atrial fibrillation.
We’ve discussed this plenty.
And here, to make sure that you prevent
an embolization type of ischemic stroke,
you’ll be using anticoagulation.
Remember the carotid artery, a common
site for maybe atherosclerosis.
And so therefore,
whatever that might be taking
place within the coronary artery
could also be taking place
within the carotid.
And so therefore,
whatever that you would be
conducting in the coronary
is something that you want to
take care of here in the carotid.
Endarterectomy in appropriate patients
and greater than 70% stenosis.
kind of behaves like the discussion
that we had with angina, right?
When you start getting into –
In the carotid artery though,
a little bit more dangerous.
In the coronary artery, remember
70% or so stable angina,
90% you get into
But in the carotid though,
70% is something that you very much
want to keep in mind and consider
with the amount of
stenosis taking place.
Control the diabetes.
The rest of these
make perfect sense.
These are preventive measures.
Please make sure that you’re
well-versed with prevention.
What’s the best type of medicine?
Unfortunately is where we stand today.
But as you know, the medical world
is moving towards prevention,
which is nice to know.
So in summary with ischemic stroke,
remember the risk factors
we’ve talked about.
We’ve talked about age, gender.
We’ve talked about hypertension being a
very important, very important risk factor.
Genetically, we talked about the autosomal
dominant condition called CADASIL.
Also, hypercoagulable states.
Preventive medicine, important.
Here, if you know that your
patient is at risk for stroke,
then try to treat the
Once again, look at those
Remember the carotid artery,
if you find that the blood flow through
the carotid artery is decreased,
then perhaps endarterectomy
Secondary, treat the
Once again, what we talked about earlier.
Signs and symptoms.
Well, here, focal weakness, sensory changes,
ataxia, vertigo, language difficulty,
well, all the symptoms that you can
expect for an ischemic type of stroke.
So now, before we absolutely close
the chapter on ischemic stroke,
remember, under stroke, you can
have it as being focal or global
and this point, we’ve
focused primarily on focal.
Under focal, approximately 80-85%
will be of ischemic type .
and then you have a smaller
percentage of hemorrhagic type.
We’re summarizing ischemic.
could be hemorrhagic.
Then you have something called Todd’s
metabolic disorders, complicated
migraines, all differentials.
Acute and post acute diagnostic
workup, we talked about that head CT.
We talked about echo, MRI,
carotid type of ultrasound
to make sure how much stenosis
is taking place in the carotids.
Treatment, we’ve talked about
the antiplatelet therapies.
We’ve talked about the great extent of tPA
and keep in mind, in