eMedicine Specialties > Neurology > Neuro-vascular Diseases
Anterior Circulation Stroke: Treatment & Medication
Updated: Sep 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The 3 medical interventions that have been shown to improve outcomes after stroke are (1) treatment in a stroke unit, (2) intravenous recombinant tissue plasminogen activator therapy administered within 3 hours of onset to patients with ischemic stroke, and (3) aspirin administered within the first 48 hours of stroke.
All patients with stroke should be admitted to the hospital and be treated in a comprehensive stroke unit with an interdisciplinary team. Treatment in a stroke unit has been shown to improve outcomes for patients. Smaller hospitals should consider models of stroke unit care that adhere as closely as possible to those used in stroke units.
Eligible patients should be transferred by Emergency Service personnel to Primary Stroke Centers for consideration of intravenous tissue plasminogen activator therapy, wherever possible. In some rural areas, telemedicine is being used for the emergency evaluation and management of patients with stroke prior to transfer to larger medical centers.
The overall aims are to reperfuse ischemic brain as quickly as possible and to prevent acute, subacute, or chronic medical and neurological complications.
- Check vital signs and perform neurological assessments.
- Check oxygen saturation; administer supplemental oxygen if hypoxic.
- Monitor cardiac function.
- Administer anticoagulants or advise compression stockings to bedridden patients to avoid deep venous thrombosis.
- Avoid indwelling bladder catheter if possible.
- Control blood pressure optimally.
Surgical Care
Emergency decompression with craniotomy is performed in some centers for patients with malignant MCA syndrome. It is a matter of debate as to whether younger patients and those with right hemisphere syndromes are preferentially operated on (because of better potential for functional recovery). The timing of surgical intervention is also critical.
Carotid endarterectomy is recommended for the secondary prevention of stroke for patients with occlusive internal carotid artery disease, for patients with 70-99% stenosis, and for some patients with 50-69% stenosis.
Consultations
The following consultations are made depending on the individual patient's needs. In some centers, specialists work as an integrated stroke team.
- Physical therapy - For assessment of difficulty in sitting, standing, or walking and the need for assistive devices to aid walking
- Speech therapy - For assessment of swallowing, language impairments, or dysarthria
- Occupational therapy - For patients with decreased cognitive or upper extremity function and need for adaptive equipment
- Social services - For discharge planning
- Rehabilitation - For assessment of rehabilitation needs
- Psychiatry - For assessment of psychiatric status
Diet
- Generally, patients are allowed nothing by mouth for the first 24 hours, except for patients with very mild or rapidly resolving deficits. Intravenous fluids should avoid dextrose and preferably involve isotonic saline.
- Perform bedside or fluoroscopic swallowing assessment. Adjust diet depending on results; if necessary to meet nutritional needs, commence nasogastric feeding.
- Assess for future need of enteral feeding (typically via percutaneous gastrostomy tube).
Activity
- Advise bed rest for the first 24 hours with the head of the bed below 30 degrees to avoid exacerbation of cerebral hypoperfusion in evolving infarcts, which sometimes can lead to neurological worsening. The focally ischemic brain has impaired autoregulatory capacity and so may not compensate for changes in blood pressure that are tolerated under nonischemic conditions. Intravenous normal saline is also administered.
- If the patient's condition is stable after 24 hours, graded ambulation with assistance may commence, depending on functional status.
Medication
Intravenous recombinant tissue plasminogen activator (rt-PA) administered within 3 hours of stroke onset is the only FDA-approved pharmaceutical therapy for the acute treatment of ischemic stroke. The administration of aspirin (in doses ranging from 30 mg to 625 mg) within the first 48 hours of stroke is also supported by pooled data from the Chinese Acute Stroke Trial (CAST) and the International Stroke Trial.1,2
Other medical management of anterior circulation ischemic stroke consists of the intravenous administration of normal saline over the first 24 hours and administration of therapies aimed at secondary stroke prevention, usually antiplatelet agents or anticoagulants, depending on the etiology of the stroke.
Antihypertensive therapy is typically deferred for 48 hours in order to prevent hypoperfusion in the ischemic penumbra. The regimen of indapamide and perindopril is supported from the results of the PROGRESS trial.3 Recent evidence indicates that high-dose statins have utility for secondary stroke prevention after stroke and transient ischemic attack, including patients without elevated cholesterol level or coronary heart disease.
Thrombolytic agents
These agents lyse thromboemboli lodged in cerebral blood vessels and restore blood flow, salvage the ischemic brain tissue, and improve clinical outcome. They must be administered within 3 hours of onset of stroke symptoms; beyond this time, the risk of intracerebral hemorrhage outweighs treatment benefits.
Alteplase (Activase)
Recombinant plasminogen activator that forms plasmin after facilitating cleavage of endogenous plasminogen. In clinical trials, has been shown effective in achieving TIMI 2 or 3 patency at 90 min.
Heparin and aspirin are not given for 24 h after tPA.
Must be given within 3 h of stroke onset. Exclude hemorrhage by CT scan. If hypertensive, lower BP with labetalol, 10 mg IV.
Adult
0.9 mg/kg IV; not to exceed 90 mg
Give bolus of 10% of total dose to be administered, infuse remainder over next 60 min
Pediatric
Not established
Anticoagulants and antiplatelets may increase risk of bleeding (do not administer aspirin, heparin, or other anticoagulants for 24 h after infusion)
Beyond 3 h after stroke onset; cerebral hemorrhage; recent stroke (within 3 mo); serious bleeding disorder or history of GI hemorrhage; BP >185/110 mm Hg; recent surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular arrhythmias, hypotension, and perfusion arrhythmias
Anticoagulants
Emergent heparin therapy may be given for specific indications, such as internal carotid artery dissection or cerebral venous thrombosis. Heparin therapy also may be commenced in conjunction with warfarin therapy for secondary prevention of high-risk cardioembolic stroke; it may be started either on admission (if not receiving rt-PA) or 3-5 days after stroke onset. Early use of IV heparin has not, however, been proven to be of benefit in clinical trials. For patients confined to bed who do not have excessive risk of hemorrhagic transformation, administer subcutaneous heparin to prevent deep venous thrombosis.
Heparin sodium
In addition to heparin sodium, low-molecular-weight heparins may be associated with lower rate of hemorrhagic complications.
Adult
100,000 U IV over 24 h
5000 U SC bid
Pediatric
Not established
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase toxicity
Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In neonates, preservative-free heparin recommended to avoid possible toxicity (ie, gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock; monitor for bleeding in peptic ulcer disease, menstruation, increased capillary permeability, and when giving IM injections
Warfarin (Coumadin)
Inhibits synthesis of 6 vitamin K-dependent proteins involved in anticoagulation system (factors II, VII, IX, X; proteins C, S). Many other coumarin derivatives are used worldwide.
Adult
Initial dose: 5 mg/d PO for 2-4 d (lower in very elderly patients)
Subsequent doses determined by INR achieved and source of embolism (INR 2-3 for most cardiac sources)
Pediatric
Not established
Extensive literature available regarding warfarin-drug interactions, with variable level of evidence; drugs that increase anticoagulant effects include co-trimoxazole, erythromycin, fluconazole, isoniazid, amiodarone, aspirin, simvastatin, sulfinpyrazone, phenylbutazone, alcohol, cimetidine, and omeprazole; drugs that inhibit anticoagulant effect include rifampin, nafcillin, cholestyramine, barbiturates, carbamazepine, sucralfate, and azathioprine; OTC NSAIDs (eg, Naprosyn, ibuprofen) and aspirin are associated with increased risk of upper GI bleeding when used with warfarin; high doses of acetaminophen can prolong INR
Documented hypersensitivity; active bleeding; heparin-induced thrombocytopenia; severe renal or hepatic disease; open wounds; gastric ulcer
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis
Antiplatelet agents
These agents are used for secondary prevention of ischemic stroke caused by atherosclerotic disease of small or large arteries. Data also support aspirin use within 48 hours of an acute ischemic stroke.
Recent trial evidence indicates that clopidogrel and the aspirin/dipyridamole combination are of similar overall efficacy.
The combination of aspirin and clopidogrel has been associated with an excess rate of hemorrhage and is not recommended for secondary stroke prevention, although it may be used in specialized circumstances, for example, in patients with coronary artery stents.
Aspirin (Anacin, Bayer Aspirin, Ascriptin, Bayer Buffered Aspirin)
Inhibits prostaglandin synthesis, preventing formation of platelet-aggregating thromboxane A2. May be used in low dose to inhibit platelet aggregation and improve complications of venous stases and thrombosis.
Adult
75-325 mg/d PO
Pediatric
Not established
Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease salicylate serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
Aspirin plus slow-release dipyridamole (Aggrenox)
Aspirin inhibits prostaglandin synthesis, preventing formation of platelet-aggregating thromboxane A2. May be used in low dose to inhibit platelet aggregation and improve complications of venous stases and thrombosis.
Dipyridamole is platelet adhesion inhibitor that possibly inhibits RBC uptake of adenosine, itself an inhibitor of platelet reactivity. In addition, may inhibit phosphodiesterase activity, leading to increased cyclic-3', 5'-adenosine monophosphate within platelets and formation of potent platelet activator thromboxane A2. European Stroke Prevention Trial 2 demonstrated that combination therapy was better than aspirin alone for prevention of recurrent stroke or transient ischemic attack.
Adult
25 mg aspirin + 200 mg dipyridamole SR PO bid (1 tab bid)
Pediatric
Not established
Aspirin: Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease salicylate serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Dipyridamole: Theophylline may decrease hypotensive effects; antiplatelet activity may increase heparin toxicity
Documented hypersensitivity; liver damage;
hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Aspirin may cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
Caution in hypotension when using dipyridamole; dipyridamole has peripheral vasodilating effects
Clopidogrel (Plavix)
Selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.
Adult
75 mg/d PO qd
Pediatric
Not established
Naproxen associated with increased occult GI blood loss; safety of coadministration with warfarin not established
Documented hypersensitivity; active pathological bleeding, such as peptic ulcer; intracranial hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients at increased risk of bleeding from trauma, surgery, or other pathological conditions; caution in patients with lesions (eg, ulcers) with propensity to bleed; prolongs bleeding time
Ticlopidine (Ticlid)
Reported to be 15% more effective than aspirin. However, is associated with risks of neutropenia and thrombocytopenia and requires regular blood testing; therefore, use in patients who do not respond to aspirin or are allergic to aspirin.
Adult
250 mg PO bid
Pediatric
Not established
Corticosteroids and antacids may decrease effects; theophylline, cimetidine, aspirin, and NSAIDS increase toxicity
Documented hypersensitivity; neutropenia or thrombocytopenia; liver damage; active bleeding disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue if absolute neutrophil count decreases to <1200/mm3 or if platelet count falls to <80,000/mm3
Antihypertensive agents
The combination of perindopril and indapamide was shown to reduce the rate of recurrent stroke by 30% at 5 years in the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), independent of baseline blood pressure. 3
Perindopril Erbumine (Aceon)
Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This increases levels of plasma renin and reduces aldosterone secretion. In kidney, the drug decreases glomerular hydraulic pressure, thereby decreasing filtration of protein.
Adult
4 mg PO qd; may increase dose; not to exceed 16 mg PO divided q12-24h
Start with lowest dose and titrate to highest level to decrease proteinuria
Pediatric
Not established
NSAIDs may reduce hypotensive effects of perindopril; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases perindopril levels; probenecid may increase perindopril levels; the hypotensive effects of ACE inhibitors may be enhanced when given concurrently with diuretics
Documented hypersensitivity; prior serious adverse event; angioedema
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Decreased coronary perfusion in aortic stenosis possible; renal failure in high-grade renal vascular disease may occur; may cause angioedema, anaphylactoid reactions, neutropenia, renal failure, hepatic failure, and cough; caution in infants susceptible to adverse hemodynamic effects
Indapamide (Lozol)
Chemically not a thiazide although its structure and function are very similar. It lacks the thiazide ring and only contains 1 sulfonamide group (thiazides have 2). The half-life of indapamide is about 14 h, so the drug can be taken just once daily. Effect on urinary calcium and hypercalciuria is identical to thiazides. Adverse effects tend to be somewhat milder than with thiazides.
Adult
0.625 mg-2.5 mg/d PO
Pediatric
Not established
Loss of diabetic control with diazoxide, sulfonylureas, and insulin; potentates toxicity of digoxin and lithium
Documented hypersensitivity; anuria; electrolyte imbalance; hypercalcemia
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Azotemia can occur; fluid/electrolyte imbalances (eg, hyponatremia, hypercalcemia, hyperuricemia, hypokalemia, hypomagnesemia, hyperchloremic acidosis, hyperglycemia, hypocitraturia)
Antilipemic agents
The stroke prevention by aggressive reduction in cholesterol levels (SPARCL) study showed that intensive cholesterol lowering in patients with minor stroke and TIA and no history of heart disease reduced that rate of fatal and non-fatal strokes.
Atorvastatin (Lipitor)
The most efficacious of the statins at high doses. Inhibits 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA reductase), which, in turn, inhibits cholesterol synthesis and increases cholesterol metabolism. Reports have shown as much as a 60% reduction in LDL-C. The Atorvastatin versus Revascularization Treatment study (AVERT) compared 80 mg atorvastatin daily to standard therapy and angioplasty in patients with CHD. While events at 18 mo were the same between both groups, the length of time until the first CHD event occurred was longer with aggressive LDL-C lowering. The half-life of atorvastatin and its active metabolites is longer than that of all the other statins (ie, approximately 48 h compared to 3-4 h).
May modestly elevate HDL-C levels. Clinically, reduced levels of circulating total cholesterol, LDL-C, and serum TGs are observed.
Before initiating therapy, patients should be placed on a cholesterol-lowering diet for 3-6 mo; the diet should be continued indefinitely.
Adult
10 mg PO qd; titrate to a maximum 80 mg/d as necessary
Dosage adjustment in renal insufficiency unnecessary
Pediatric
Not established
Toxicity increases when coadministered with triazole antifungals, CNS depressants, macrolide antibiotics, gemfibrozil
Documented hypersensitivity; significant hepatic impairment
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Do not exceed daily dose; caution in patients receiving drugs which prolong QRS or Q-T interval
More on Anterior Circulation Stroke |
| Overview: Anterior Circulation Stroke |
| Differential Diagnoses & Workup: Anterior Circulation Stroke |
 Treatment & Medication: Anterior Circulation Stroke |
| Follow-up: Anterior Circulation Stroke |
| Multimedia: Anterior Circulation Stroke |
| References |
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Further Reading
Keywords
carotid artery territory ischemic stroke, major hemispheric syndrome, middle cerebral artery stroke, MCA stroke, MCA syndrome, anterior cerebral artery stroke, ACA stroke, lacunar stroke, reperfusion, anterior circulation stroke
