About Stroke

● Sudden confusion, talking difficulty, or difficulty understanding speech

● Suddenly feeling numb or weak in the face, arm, or leg, especially on only one side of the body 

● Sudden onset of a severe headache

● Suddenly having trouble seeing in one or both eyes 

● Suddenly having trouble walking, dizziness, loss of balance, or lack of coordination 

Call 911 if you or you are noticing anyone experiencing these above symptoms. If your symptoms go away within 24 hours, you may have had a transient ischemic attack (TIA), and should contact your primary care physician as soon as possible. 

There are 3 types of stroke: 

1. An ischemic stroke occurs when blood clots or other brain materials block the blood vessels to the brain. The subtypes of ischemic strokes are: 

● Thrombosis: Thrombus formed in larger or small blood vessel 

● Embolism: multiple acute strokes due to plaques from multiple possible sources 

● Systemic hypo-perfusion 

2. A hemorrhagic stroke, which occurs when a blood vessel bursts in the brain. This may be due to:

● Hypertensive ICH 

● Bleeding disorder 

● Lobar or atypical hemorrhage – Amyloid angiopathy, bleeding into a tumor, vascular malformations, or drug use 

3. Venous thromboembolism

• Tissue plasminogen activator: (TPA/alteplase, which is used to dissolve blood) to start within 4.5 hours of symptom onset (Refer to the IV tPA Screening Checklist before tpa/thrombolytic therapy is started, the blood pressure should keep less than or equal to 180/105 mmHg for at least 24 hours).
• Mechanical thrombectomy within 24 hrs of symptoms onset if the patient has large vessel occlusion and rescuable brain tissue.
• Asa/Plavix within 48 hours of stroke onset, deep vein thrombosis, and aspiration prevention.
• Risk factors modification such as smoking/alcohol/atrial fibration (need anticoagulant if CHA2DS2 score > or = 1 in male and > or = 2 in female), diabetes ( the goal is less than 7% of HbA1c), uncontrolled Bp and cholesterol, exercise and/or weight loss if obesity, diet change if needed, and/or rehabilitation for illegal substance abuse.
• BP control.
• Ischemic stroke — if not treated with tpa, Bp should be treated if Sbp >220 mmHg or DBP >120 mmHg), But if pt has active CAD, CHF, aortic dissection, or pre-eclampsia/eclampsia, if treatment is indicated, then lower BP by 15 percent during the first 24 hours.
• Start treatment for HTN with > 140/90 in 24-48 hrs after onset stroke. The goal is to control Bp in a few days to a week. However, this is a different criterion if the patient has intracranial or extracranial artery stenosis. 
• Start treatment HTN with SBp <130 with small vessel stroke.
• Start treatment HTN with S Bp <120 and help decrease any stroke by 41%.
• Blood pressure in acute hemorrhagic stroke.
• Lower Sbp less than 140 if Sbp 150-220.
• Lower Bp 140-160 if Sbp >220.

• Low-risk TIA, defined by an ABCD2 score <4. Start aspirin (162 to 325 mg/daily) alone.
• High-risk TIA, ABCD2 score ≥4, suggest using dual antiplatelet therapy (DAPT) using aspirin (160 to 325 mg loading dose, followed by 50 to 100 mg daily) plus clopidogrel (300 to 600 mg loading dose, followed by 75 mg daily) for the first 21 days.
• If the patient is on aspirin or clopidogrel at the time of TIA onset, we suggest aspirin plus clopidogrel for the first 21 days for high-risk TIA (an ABCD2 score of ≥4).