CEREBROVASCULAR ACCIDENT AND ITS MANAGEMENT

BY:
PHARM DAHIRU ISMAIL GURAI

PHARMACY DEPARTMENT

FEDERAL UNIVERSITY OF HEALTH SCIENCES TEACHING HOSPITAL, AZARE.

PRECEPTOR: PHARM KABIRU BABAYO (PRINCIPAL PHARMACIST)

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OUTLINE
INTRODUCTION
CLASSIFICATION
PATHOPHYSIOLOGY
SIGNS AND SYMPTOMS
RISK FACTORS
MANAGEMENT
ROLE OF PHARMACIST
CONCLUSION
REFERENCES

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INTRODUCTION
Cerebral vascular accident (CVA), cerebrovascular disease, stroke or “brain
attack” is an acute CNS injury that results in neurologic sign and symptoms
brought on by a reduction or absence of perfusion to a territory of the brain.
The disruption in flow is from either an occlusion (ischemic) or rupture
(hemorrhagic) of the blood vessel.
A leading cause of serious long-term disability in adults. In 10% of patients with
myocardial infarction, stroke will occur within the next 5 years

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According to WHO;
Stroke is a neurological deficit (usually loss of function) caused by reduction in
blood supply to the brain. This is usually because a blood vessel bursts or is
blocked by a clot. This affects the supply of oxygen and nutrients, causing
damage to the brain tissue.

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INCIDENCE & PREVALENCE
There is no comprehensive epidemiological information about stroke in Nigeria
Stroke is the 3rd leading cause of death in the US, and the first cause of death
worldwide
◦ 795,000+ people/year,
◦ 175,000 die within one year (25%)

Leading cause of long-term disabilities

◦ 5.5 million survivors (USA), 15 to 30 % live with permanent disability
◦ The cost of stroke in the US is over 68 billion dollars annually

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Stroke accounts for 10% of all mortality

Tuberculosis Malaria
Diarrhoea
Perinatal causes
2% Other causes
3% 3%
Chronic obstructive pulmonary 4%
disease 27%
5%
HIV/AIDS 5%

Respiratory infections 7%
Coronary heart
disease
9%
13%
Accidents Stroke Cancer
12%
10%

Since 80s, a significant increase (> 2-fold ) has been noticed in incidence of stoke :
1–2 /1.000 people in USA, 2–2.5/1.000 in Western και 3–3.5/1.000 in Eastern
Europe 6
American Stroke Association. Heart Disease and Stroke Statistics 2004
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CLASSIFICATION OF STROKE
Two major categories:
Ischemic strokes: caused when a blood vessel supplying the brain is occluded by a clot.
Responsible for 85 - 88 % of all strokes.

Hemorrhagic strokes: caused when a cerebral artery ruptures.

Both forms are life threatening.

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Ischemic Stroke
Constitute 85 - 88 % of all strokes
Most patients with ischemic stroke do not have a decreased level
of consciousness in the first 24 hours
80% of Ischaemic stroke is caused by embolism from:
Heart
Aortic arch
Extracranial arteries to the brain

Subtype:
Thrombotic
Embolic
Transient ischemic attack

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Hemorrhagic Stroke
• Accounts for approximately 15% of all strokes

• Subtype:
• Intracerebral hemorrhage (ICH): may results from
hematomas and high BP.

• Subarachnoid hemorrhage (SAH): may result from head

injury, rupture of arterial aneurysm, or spread of blood
from different location to subarachnoid space

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 Hemorrhagic Stroke

occurs when a blood vessel ruptures and bleeds into the brain

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RISK FACTORS FOR STROKE
Although some strokes occur without warning, most stroke victims have prior risk factors.
Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.

Risk Factors are classified as;

Modifiable risk factors
Non Modifiable Risk factors

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NON MODIFIABLE RISK FACTORS
Age
◦ 2/3 over 65
Gender
◦ M=F
◦ Female>fatality

Race/ethnicity
Heredity
◦ Family history
◦ Previous TIA/CVA

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 MODIFABLE RISK FACTORS
WELL DOCUMENTED LESS WELL DOCUMENTED
Hypertension Obesity

Smoking Physical Inactivity

Poor Diet/Nutrition
Diabetes
Alcohol Abuse
Asymptomatic Carotid Stenosis
Drug Abuse
Atrial Fibrillation
Hypercoagulability
Hyperlipidemia
Hormone Replacement Therapy
Sickle Cell Disease Oral Contraceptive Use
Other cardiac diseases Inflammatory Process

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COMMON SIGNS AND
SYMPTOMS OF STROKE
S/S OF STROKE HEMORRHAGIC STROKE

oSUDDEN numbness or weakness of face, Distinguishing Features:

arm, or leg, especially on one side of the body 
Appear more seriously ill
oSUDDEN confusion, trouble speaking or Deteriorate more rapidly
understanding
Severe headache
oSUDDEN trouble seeing in one or both eyes
Alteration in consciousness
oSUDDEN trouble walking, dizziness, loss of
balance or coordination Nausea and/or vomiting
oSUDDEN severe headache with no known Neck pain
cause Intolerance of noise or light

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PATHOPHYSIOLOGY OF HEMORHAGIC
STROKE

↑ Increase Pressure Rupture of the Blood

Hypertension
to the Blood Vessels Vessels

Neuronal Compression of the

Dysfunction blood vessels Bleeding
Adjacents to the Brain
tissue.
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PATHOPHYSIOLOGY OF ISCHEMIC
STROKE
Occulution of Blood ↓ Oxygenation and
↓ Blood Flow
Vessel nutrition of the brain

↓ Energy stores

↑ Ca+, Na+, Cl- Opening Ca+ ↑ Glutamine and Aspatate

Cell Death
Decrease K+ Channels

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How To Know If Someone Is
Having Stroke
F acial weakness - can the person smile? Has
their mouth or eye drooped?

A rm weakness - can the person raise both

arms?

S peech problems - can the person speak

clearly and understand what you say?
T est – all 3

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DIAGNOSIS TESTS
◦ Non-contrast brain CT scan or brain MRI
◦ Blood glucose
◦ Serum electrolytes/renal function tests
◦ ECG
◦ Markers of cardiac ischemia
◦ Complete blood count, including platelet count
◦ Prothrombin time/INR
◦ Oxygen saturation

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Manifestations of Right-Brain and Left-Brain Stroke

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PREVENTION OF STROKE
Primary prevention:
•Primary stroke prevention refers to the treatment of individuals with no history of
stroke but are at risk.
•Risk-reduction measures in primary stroke prevention may include:
•Control modifiable risk factors
•Smoking cessation
•Dietary intervention
•Weight loss and exercise

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 MANAGEMENT OF ACUTE ISCHEMIC STROKE
Thrombolysis
This lyses clot by digesting fibrinogen
Is achieved by given intravenous recombinant tissue plasminogen activator (tPA - Alteplase)
0.9mg/kg within 4.5hours of attack
10% of the dose is administered over 1 minute and the remaining dose over 1 hour.
Reduces death and disability at 90 days
Side effects
Bleeding at the insertion site of IVF, urinary catheter,NGT
Intracranial bleeding.

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Antiplatelets

In acute stroke aspirin is the only proven antiplatelet agent.

Aspirin 300mg within 48 hours continued for 14 days
reduces 14 day mortality and morbidity.

Cochrane review on various trials on stroke treatment has demonstrated no

evidence for:
• Anticoagulants
• Combinations of antiplatelets or antiplatelets with anticoagulants
• Neuroprotectants
for acute stroke

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Other therapies:
Blood pressure - not actively managed in acute phase.

Hydration – IV Sodium Chloride 0.9% is preferred to glucose 5%.

Blood glucose - treat if blood glucose is >11mmol/L using

appropriate agent.

Oxygen - supplemental Oxygen if saturation <95%.

Temperature – prescribe antipyretics (paracetamol), physical

cooling can be used in addition to antipyretics.
Adjunct Drugs- Vitamin C po 200mg tds, Vitamin E po 400iu daily.

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ACUTE MANAGEMENT OF HEMORRHAGIC STROKE

Treatment is centered on addressing the cause.

Hypertension accounts for 60% of hemorrhagic stroke.
SBP should be kept < 180mmHg within 1 hour and maintained for the next 24
hours, aggressive drop of BP should discouraged.
1. Vasospasm.
Calcium-Channel blocker can be used (due to their vasodilation)
DRUG DOSE SIDE EFFECTS
Nimodipine 60mg q4hours Hypotension, Weight gain
Verapamil 40-120mg in divided doses Hypotension, Insulin release
Nifedipine 20-100mg in divided doses Hypotension, Headache,
Dizziness
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2. Systemic Hypertension
•Antihypertensive agents for ICH (intracerebral hemorhage) have not been compared in
controlled trials.
DRUG DOSE SIDE EFFECTS

Labetalol IV 50-300mg PRN Hypotension, Heart failure,

Bradycardia
Enapril PO 5-40mgDaily/Bd Dry cough,Dizziness,
hyperkalemia
Nicardipine IV 5-15mg q8h Tachycardia, Heart Failure

Hydralazine IV 20-40mg PRN Tachycardia, Arrythmias

Nitroprusside IV 0.2-1mg/Kg PRN Hypotension,Bradycardia

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3. Treatment of Increased ICP

•Elevate head of bed to 30 degrees

•Analgesia and sedation as needed

Aggressive therapies:
Osmotic therapy
Mannitol
Hypertonic Saline
Barbiturate anesthesia
Hyperventilation and glucocorticoids not recommended

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4. Management Of Glucose
•High blood glucose on admission predicts an increased risk of mortality and poor outcome in
patients with and without diabetes and ICH.
• Use of insulin is controversial. Hypoglycemia should be avoided.

5. Management of Seizures
• Patients with a change in mental status and whose EEG shows electrographic seizures should
receive treatment.
DRUG DOSE SIDE EFFECTS

Diazepam IV 10-30mg PRN Dizziness, Decrease Heart

rate
Carbamazepine PO 200-800mg In Divided doses Decrease BP, Dizziness
Phenytoin IV 3-4mg PRN Dizziness, Confusion

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 PREVENTION OF STROKE
Primary prevention:
•Primary stroke prevention refers to the treatment of individuals with no
history of stroke but are at risk.
•Risk-reduction measures in primary stroke prevention may include the use of:
•Control modifiable risk factors
•Smoking cessation
•Dietary intervention
•Weight loss and exercise

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Secondary Prevention:
•Patients surviving an initial stroke are known to be at significantly increased risk for further
stroke(s) compared to the general population.
•Secondary prevention can be summarized by the mnemonic A, B, C, D, E, as follows:
•A - Antiaggregants (aspirin, clopidogrel, extended-release dipyridamole) and anticoagulants
(warfarin)
•B - Blood pressure–lowering medications
•C - Cessation of cigarette smoking, cholesterol-lowering medications, carotid
revascularization
•D – Diet
•E – Exercise

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REHABILITATION OF STROKE PATIENTS

After the stroke has stabilized for 12-24 hours, collaborative care shifts from
preserving life to lessening disability and attaining optimal functioning.
It involve interdisciplinary team:
◦ Physicians
◦ Pharmacist
◦ Nurses
◦ Occupational therapists
◦ speech-language therapists
◦ Psychologists
◦ social workers
◦ recreational therapists
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ROLES OF PHARMACIST
◦ The Roles of Pharmacist include:
◦ Identify and treat underlying cause.
◦ Patient and caregiver education.
◦ Monitor And treat adverse drug reactions.
◦ Promote medication adherence through reminders and follow up calls.
◦ Participate in a multidisciplinary team to Optimize patient outcomes.
◦ maximize functional independence.
◦ promote resumption of patients pre-existing lifestyle.
◦ facilitate psychologic & social adaptation.

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REFERENCES
1. Abbas, A. K.,Robbins and Cotran pathologic basis of disease (10th ed.). Elsevier.
2. Adams, H. P.,American Heart Association; American Stroke Association Stroke Council. (2007).
Guidelines for the early management of adults with ischemic stroke. Stroke, 38(5), 1655–1711.
[Link]
[Link] Institute of Neurological Disorders and Stroke. (n.d.). Stroke information page.
National Institutes of Health. [Link]
[Link], W. J.,Guidelines for the early management of patients with acute ischemic stroke: 2021
update from the American Heart Association/American Stroke Association. Stroke, 52(4), e364–
e467. [Link]
[Link] Health Organization. (2023). Stroke: Key facts. [Link]
sheets/detail/stroke

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THANK YOU FOR LISTENING

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