Drug Treatment of Acute Ischemic Stroke
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THERAPY IN PRACTICE
Drug Treatment of Acute Ischemic Stroke Sameer Bansal • Kiranpal S. Sangha Pooja Khatri
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Published online: 5 February 2013 Springer International Publishing Switzerland 2013
Abstract Acute ischemic stroke (AIS) is the fourth leading cause of death and the leading cause of adult disability in the USA. AIS most commonly occurs when a blood vessel is obstructed leading to irreversible brain injury and subsequent focal neurologic deficits. Drug treatment of AIS involves intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator [rtPA]). Intravenous alteplase promotes thrombolysis by hydrolyzing plasminogen to form the proteolytic enzyme plasmin. Plasmin targets the blood clot with limited systemic thrombolytic effects. Alteplase must be administered within a short time window to appropriate patients to optimize its therapeutic efficacy. Recent trials have shown this time window may be extended from 3 to 4.5 hours in select patients. Other acute supportive interventions for AIS include maintaining normoglycemia, euthermia and treating severe hypertension. Urgent anticoagulation for AIS has generally not shown benefits that exceed the hemorrhage risks in the acute setting. Urgent antiplatelet
S. Bansal Visiting Student, Department of Neurology, University of Cincinnati, College of Medicine, Cincinnati, OH, USA K. S. Sangha Clinical Pharmacy Specialist – CNS, UC Health University Hospital, University of Cincinnati, College of Pharmacy, Cincinnati, OH, USA
use for AIS has limited benefits and should only promptly be initiated if alteplase was not administered, or after 24 hours if alteplase was administered. The majority of AIS patients do not receive thrombolytic therapy due to late arrival to emergency departments and currently there is a paucity of acute interventions for them. Ongoing clinical trials may lead to further medical breakthroughs to limit the damage inflicted by this devastating disease.
1 Introduction Stroke is the fourth leading cause of death and the leading cause of disability in the elderly in the USA. Every year, about 795,000 new or recurrent strokes occur, which cost an estimated US$73.7 billion in 2010 alone. Ischemic stroke, or disruption of blood flow to the brain, accounts for about 85 % of all strokes [1]. We discuss the medications related to ischemic stroke care in the context of the overall treatment approach towards the patient. This approach consists of four main goals: •
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• P. Khatri (&) Department of Neurology, University of Cincinnati, College of Medicine, 260 Stetson St, Ste 2300, ML 0525, Cincinnati, OH 45267-0525, USA e-mail: [email protected]
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The first goal of the evaluation of a suspected ischemic stroke is to exclude intracranial hemorrhage with neuro-imaging. Second, the advisability for acute treatment with thrombolytic agents and endovascular device therapies must be considered, and general supportive care must be administered. Third, acute medical or neurologic complications of stroke must be anticipated. Finally, the
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