Running head: STROKE TREATMENTS

Stroke Pharmacologic and Non-pharmacologic Treatments
Mitchell Taylor
N839 Management of Acute and Chronic Health Problems of the Adult
Wichita State University

Stroke Pharmacologic and Non-pharmacologic Treatments
Overview of Topic
Stroke is a devastating disease that is estimated to affect 5,600,000 adults in the United States (American Heart Association, 2007, Heart Disease and Stroke Statistics, p. e72).    This statistic does not take into account the people with high blood pressure and other cardiovascular diseases that affect up to 79,400,000 adult Americans that put a patient at risk for a stroke (American Heart Association, 2007, Heart Disease and Stroke Statistics, p. e72).    With these statistics in mind, a provider needs to consider the treatment of stroke as not only affecting the stroke disability, but also the treatment of the other cardiovascular disease that places one at risk for having another stroke.  The author will analyze pharmacologic and non-pharmacologic interventions based on the current literature for the treatment of ischemic stroke.  
	In order to understand the treatments one must first understand a little about stroke.  A stroke is a sudden disruption of blood supply to the brain that causes an irreversible neurologic impairment (Sauerbeck, 2006, p. 40).  Stroke occurs in two types, ischemic and hemorrhagic.  An ischemic stroke accounts for 80-85% of strokes which manifests itself by a blockage of a vessel to the brain.  The subtypes of ischemic stroke describe the type and the suspected cause of the stroke and include:  large vessel thrombotic and embolic stroke usually caused by hypoperfusion, hypertension, and arteriogenic emboli from large arteries that move to distal branches, small vessel thrombotic stroke caused by plaque, diabetes, or hypertension,  cardioembolic stroke from atrial fibrillation, valve disease, or ventricular thrombi, other causes that have prothrobotic causes such as drug abuse, and unknown causes (Morrison, 2007, p. 39).  Hemorrhagic stroke is when a blood vessel is ruptured and blood leaks into other structures of the brain.  The most common cause of this is hypertension (Morrison, 2007, p. 39).   
	The American Heart Association and American Stroke Association have released the 2007 national guidelines for early management of adults with ischemic stroke.  This updates the last 2005 guideline. The guideline has been updated since 1994 when it was first issued (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, 2007, p. 1655-1711).  The guideline cites the evidence and grades that evidence for each treatment option and offers recommendations based on the strongest evidence available.
Pharmacologic Interventions
	The treatment of a stroke involves differentiating between ischemic versus hemorrhagic.  This is important to determine because treatment will be directed differently based on this finding.  A computed tomography (CT) scan of the brain without contrast is still preferable to Magnetic Resonance Imaging (MRI) in the acute stage because it is quicker and more reliable in detecting intracranial hemorrhage although ischemia may not show up on the CT scan for 24-48 hours after an ischemic stroke (McPhee & Papakakis, eds., 2007, p. 1017, 1019).  As MRI studies become faster and more reliable in detecting hemorrhagic stroke, this will no doubt become more controversial in which should be the first line diagnostic tool for brain imaging.  	Once a hemorrhage has been ruled out, the next consideration would be to implement recombinant tissue plasminogen activator (rtPA).  It is a thrombolytic agent that is approved by the Food and Drug Administration (FDA) for use in certain patients having an ischemic stroke.  It has been shown to improve outcomes in ischemic stroke patients if given intravenously within the first three hours of symptom onset (Saver & Yafeh, 2007, 418).   This supports evidence from the ATLANTIS trial and the NINDS trial (Albers, Clark, Madden, and Hamilton, 2002, p. 493-496) and (NINDS study group, 1997, p. 2109-2118).  The problem with rtPA are several.  One it has to be given intravenously within 3 hours (up to 6 hours intraarterially from a specialized stroke center and is not FDA approved) from onset of symptoms. This alone limits its use to about 3% of ischemic stroke patients, and it can cause bleeding in about 5-6% of patients who do receive it (Becker and Wira, 2006).  The inclusion criteria are complex as well making a more difficult decision to select a patient who will qualify.  These are the inclusion criteria:  
	diagnosis of ischemic stroke causing measurable neurologic deficit, neurologic signs 
	should not be clearing spontaneously, neurologic signs should not be minor and isolated, 
	caution should be exercised in treating patients with major deficits, symptoms should not 
	be suggestive of subarachnoid hemorrhage, onset of symptoms <3 hours before 
	beginning treatment, no head trauma or prior stroke in past 3 months, no MI in prior 3 
	months, no GI/GU hemorrhage in previous 21 days, no arterial puncture in 
	noncompressible site during prior 7 days, no major surgery in prior 14 days, no history of 
	prior intracranial bleed, SBP <185, DBP <110, no evidence of acute trauma or bleeding, 
	not taking an oral anticoagulant, or if so INR <1.7, if taking Heparin within 48 hours 
	must have a normal activated prothrombin time (apt),  platelet count >100,000, blood 
	glucose level greater than 50 mg/dL (2.7 mmol), no seizure with residual postictal 
	impairments, CT does not show evidence of multilobar infarction (hypodensity >1/3 
	hem), and the patient and family understand the potential risks and benefits of therapy 	(Becker and Wira, 2006).
This takes into account several items including lab testing and assessment data including vital signs monitoring.  This also prevents the use of anticoagulants for 24 hours (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1667). 
	Anticoagulation therapy has been the subject of some debate.  Heparin has been the mainstay of therapy in the past for treating acute ischemic stroke.  According to the current guideline studies have not shown an improvement in outcome of the stroke patient, but has shown an increase in intracranial hemorrhage; therefore, the guideline does not recommend use of anticoagulation except for the use of preventing deep vein thrombosis (DVT) in those patients by day 2 of hospitalization recognizing that there are nonpharmacologic methods to prevent DVT (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1667).  
	The patients with acute ischemic stroke presenting within 48 hours of symptom onset should be given aspirin (325 mg/day) to reduce stroke mortality and decrease morbidity, provided contraindications such as allergy and gastrointestinal bleeding are absent, and the patient has or will not be treated with rtPA (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1681).  The Chinese Acute Stroke Trial (CAST) and the International Stroke Trial (IST) are 2 large studies which evaluated aspirin 160-300 mg/d within 48 hours of ischemic stroke symptom onset.  Compared with no treatment, they confirmed aspirin resulted in a 1% absolute reduction in risk of stroke and death in the first few weeks.  Aspirin reduced mortality in about 1% at 6 months (Silver and Lorenzo, 2007).  Abciximab (ReoPro) study was stopped when efficacy was questioned in the light of high mortality rates.  Symptomatic intracranial hemorrhage occurred in 3.6% of patients on abciximab and in 1% of patients on placebo (Silver and Lorenzo, 2007).   Although these medications are used as mainstays in preventing stroke, they are not currently recommended in the acute treatment of stroke. 
	Other agents for consideration include neuroprotectants agents.  These agents that prevent ischemia have been examined with mixed results.  Currently, there is not enough evidence to recommend any neuroprotective medications in the guideline (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1687).  Hemodilution and vasodilation in acute ischemic stroke have had mixed results as well.  Hemodilution is not recommended due to evidence shows decreased oxygen carrying capacity and vasodilation is not recommended.  The question of hypertension is difficult because of the inclusion criteria for those receiving rtPA, SBP < 180 and DBP < 110, and those who do not receive it rtPA SBP > 220 or DBP > 120mmHg is recommended to be treated.  These numbers have little supporting evidence, but clinical trials of medications that rapidly reduce blood pressure have consistently confirmed poor outcomes.  The guidelines offer only approaches to treat elevated BP for rtPA administration including with Labetalol 10-20mg IV over 1-2 minutes or Nitropaste 1-2 inches or Nicardipine infusion 5mg/hr to maximum dose of 15mg/hr in the acute phase, otherwise it recommends a clinical approach to restarting patient’s home blood pressure medications at least 24 hours after the stroke event and to reduce extremely elevated BPs to about 15% in the first 24 hours (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1671).  
	Hyperglycemia has been thought to cause acidosis and edema in the brain.  It is currently recommended to treat patients without dextrose in the IV, running normal saline.  The question of hypertonic solutions has mixed results as well.  The current recommendation is to lower the blood glucose levels to less than 140 – 180 mg/dL.  This seems to be a liberal estimate of controlling blood sugar with growing evidence in other critically ill patients that blood sugar levels should be in much tighter control (Schrier, 2006, 285). 
Nonpharmacologic Interventions
The patency of the airway of a patient remains the foremost importance for nonpharmacologic interventions.  This recommendation has not changed from previous guidelines (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1673).   Supplemental oxygen is generally applied to patients with stroke where airway compromise have been found or when pulse oximetry show an oxygen saturation lower than 90-92%, but there is no supporting evidence that oxygen therapy alone improves outcomes.  There were some studies that utilized hyperbaric oxygen therapy, oxygenation under pressure, but no improvements in outcomes have been demonstrated (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1673).  
	High temperatures are associated with worse clinical outcomes and new evidence is suggesting that induced hypothermia may have some neuroprotective effects in ischemia.  Not enough evidence is available to make a recommendation and determining details of how low to let the temperature go before platelet shearing occurs has yet to be answered  (Hemmen, and Lyden, 2007, p. 794).  ECG monitoring, echocardiogram, carotid and venous doppler studies, and prevention of deep vein thrombosis are all items frequently used to determine, treat, and prevent secondary injury in stroke patients.  
	With decreased level of consciousness, difficulty swallowing and speaking, aspiration pneumonia is a risk for the ischemic stroke patient.  There is not a national guideline that endorses a particular dysphagia screen; however, there is supporting evidence that formal dysphagia screens prevent aspiration pneumonia if they have certain components such as a formal  assessment of risk factors for problems swallowing, evaluation to be followed up by a speech therapist, swallowing with a small amount of water if no risks exist, and the patient is to be NPO prior to the screen or evaluation by speech therapy (Hinchey, Shephard, Furie, Smith, Wang,  and Tonn, 2005, p. 1973).  
	Several assessment scales have been used in the evaluation of the patient with decreased level of consciousness.  The National Institutes of Health Stroke Scale (NIHSS)has been studied to look as specifically stroke patients and their disabilities and provide an understanding of how severe the stroke is.  It is the only scale recommended in the national stroke guideline in acute treatment of a stroke with rationale being that a consistent and comprehensive evaluation of stroke is necessary for these patients realizing that some education needs to be completed to accurately utilize the scale (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1665).
	An emerging field of study with ischemic stroke patients is arteriography and mechanical clot extraction through intracranial arteries.  There is one device that is approved by the FDA for use in clot extraction, but there is not enough evidence to recommend it in the guideline (Adams, Zoppo, Alberts, Bhatt, Brass, Furlan, et. al., 2007, p. 1684).  As technology improves, it will no doubt become more widely studied for efficacy in outcomes. 
	This discussion focused on pharmacologic and nonpharmacologic treatment of acute ischemic stroke.  This discussion did not speak to the numerous pharmacologic and nonpharmacologic interventions available for prevention of ischemic stroke or treat the underlying risk factors for stroke.  As technology improves, many more options appear to be on the horizon the will help the advanced practice nurse develop safe and effective care for the acute ischemic stroke patient. 
References
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