Stroke Types and Treatment Strategies

SEPTEMBER 12, 2016
It’s astonishing to think a stroke can occur at any time and possibly leave an individual disabled for the rest of his or her life. Also shocking is the fact that a stroke occurs every 40 seconds.1

Clinical signs and symptoms may include slurring of words, single-sided facial drooping, and inability to keep both arms elevated. Time is critical, so medical assistance is necessary at any indication of a stroke, and it’s important to note the time when symptoms begin occurring because brain cells start dying as soon as the stroke occurs.
Strokes are categorized as hemorrhagic and ischemic.

Hemorrhagic Stroke
This can occur when a brain aneurysm bursts or a blood vessel in the brain leaks blood. It’s less common than ischemic stroke, but it usually results in death. Hemorrhagic stroke can be further classified into intracerebral or subarachnoid hemorrhage (SAH).1

High blood pressure is a common cause for intracerebral hemorrhage, which occurs when blood leaks into surrounding brain tissue, damaging brain cells. This may cause parts of the brain to stop working properly.1

SAH occurs when there’s bleeding in between the brain and the tissue covering the brain. A common cause of this type of stroke is bursting of an aneurysm or traumatic brain injury.1 Using blood thinners could also potentially cause SAH.

Ischemic Stroke
This occurs due to presence of blood clots in blood vessels that carry blood to the brain. Poor perfusion to the brain causes brain damage due to lack of oxygen. Ischemic strokes occur due to either embolism or thrombosis.

Embolic strokes occur when a blood clot travels from a distal area in the body to the brain-blocking blood vessels from perfusing brain tissue.1 This type of ischemic stroke is common in patients with atrial fibrillation.
 
Thrombotic strokes are caused by blood clots forming in arteries that supply blood to the brain.1 Patients with high cholesterol levels and atherosclerosis are at risk of experiencing this type of stroke.

Stroke Prevention
It’s fortunate that strokes can be preventable with lifestyle changes. In fact, up to 80% of strokes can be prevented.1 Simple changes in daily diet and exercising can help prevent individuals from experiencing such a life-changing event. Increasing intake of vegetables and whole grains and limiting intake of sodium and solid fats will help begin the journey of living a healthy lifestyle.2

Limiting intake of salt will help maintain a healthy blood pressure and reduce incidence of weakened blood vessels. Daily physical activity can help reduce the risk of stroke. Recent study results showed individuals who exercise 5 or more times per week have a reduced stroke incidence.1 Physical activities don’t have to be strenuous. A simple walk or bike ride around the neighborhood will improve overall health.

Smokers have a doubled risk of stroke compared with nonsmokers.2 Smoking can increase triglyceride levels, buildup of plaque, narrowing of blood vessels, and formation of blood clots.3 This is especially true for patients suffering from hyperlipidemia. Smoking can be hard to quit, so it’s important for patients to stay motivated when it may seem impossible. Smoking is one factor that can be eliminated and ultimately change a patient’s life.

Stroke Treatment
Patients who experience intracerebral hemorrhaging may be given mannitol to help reduce the intracranial pressure (ICP), which alleviates unnecessary pressure inside the skull.4 Elevating the head to a 30-degree angle can also help with managing ICP.

Patients experiencing SAH may be given nimodipine to help manage vasospasms that commonly occur after SAH.5 Nimodipine is a calcium channel blocker approved by the FDA for use in treatment of vasospasms.

Acute treatment of ischemic stroke may include use of alteplase, which causes fibrinolysis and breaks up the clot. Patients who experience a stroke may be placed on treatment regimens that include antiplatelets or anticoagulants to prevent further strokes from occurring in the future.

Antiplatelet agents may include aspirin, clopidogrel, dipyridamole, or ticlopidine.6 These agents work by inhibiting the production of thromboxane, which is important in the healing process of cuts and scratches. Anticoagulants may include warfarin, apixaban, dabigatran, or rivaroxaban.6

Some patients may be able to completely recover from stroke through physical therapy and rehabilitation. Other patients may experience lifelong disabilities that may improve through rehabilitation and lifestyle modifications. Stroke affects each individual differently and may cause various limitations. It’s important to be conscious of stroke signs and symptoms. The sooner a patient receives medical attention, the less brain damage will result. Time is a crucial factor in the overall recovery of a patient experiencing a stroke. 

References
1. National Stroke Association. What is stroke? stroke.org/understand-stroke/what-stroke. Accessed September 1, 2016.
2. National Stroke Association. Lifestyle Risk Factors. stroke.org/understand-stroke/preventing-stroke/lifestyle-risk-factors. Accessed September 1, 2016
3. CDC. Smoking and Heart Disease and Stroke. cdc.gov/tobacco/campaign/tips/diseases/heart-disease-stroke.html. Accessed September 2, 2016.
4. Sahni R, et al. Management of intracerebral hemorrhage. Vasc Health Risk Manag. 2007;3(5):701-709. Accessed September 3, 2016
5. Keyrouz SG, et al. Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage. Critical Care. 2007;11(4):220. Accessed September 3, 2016.
6. American Heart Association/American Stroke Association. Anti-clotting agents explained. strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStroke/ManagingMedicines/Anti-Clotting-Agents-Explained_UCM_310452_Article.jsp#.V89gVPkrLIU. Accessed September 3, 2016.


Shivam Patel, Pharm.D.
Shivam Patel, Pharm.D.
Dr. Shivam Patel has graduated from Lake Erie College of Osteopathic Medicine (LECOM) School of Pharmacy with a Doctor of Pharmacy degree. He is a PGY1 Pharmacy Resident at Martinsburg VA Medical Center. His professional interests include critical care, infectious disease, and ambulatory care. After completion of his PGY1 residency, Dr. Patel hopes to continue to serve veterans and become a Clinical Pharmacy Specialist.
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