Stroke is a serious medical emergency resulting in
permanent damage to the brain. The risk factors of stroke are diabetes,
hypertension, old age, cigarette smoking, atrial fibrillation, high cholesterol
level, high alcohol intake, previous stroke history and family history.
Broadly stroke can be of two types-ischemic or
hemorrhagic. Ischemic type is more common than the hemorrhagic one and accounts
for about 85
to 87 percent
of stroke cases.
When the artery supplying the brain is blocked,
ischemic stroke occurs. Thrombotic stroke is the condition where a blood clot
is formed in the vessels and reduces the supply of blood to the brain.
Hemorrhagic stroke occurs when the blood vessels supplying blood to the brain
ruptures. The blood clots and damages the brain tissues.
Causes of Ischemic Stroke:
There are four main causes of ischemic stroke. They
are as under:
- obstruction caused by embolism
- Obstruction caused by a blood clot that hampers
the blood flow in an artery
• Venous Thrombosis
- It is a rare cause of ischemic stroke where blood
clot obstructs the dural venous sinus draining blood from the brain.
• Systemic Hypoperfusion
- Generalized reduction in blood
supply as in shock
- When there is no obvious
known cause of stroke, it is termed as cryptogenic strokes or strokes with
unknown origin. About 30 percent to 40 percent of ischemic strokes are
On the basis of location of bleeding, haemorrhagic
strokes are of two types:
1. Extra-axial Hemorrhagic
- the blood vessels is ruptured
between the brain and the skull. Main types of extra-axial hemorrhages are:
• Epidural hematoma
(hemorrhge between the dura mater and the skull)
• Subdural hematoma
(Bleeding in the dural space)
• Subarachnoid Hemorrhagic
(Bleeding between the arachnoid
space and pia mater)
2. Intra-axial Hemorrhagic
- blood vessels within the brain
ruptures. This can be
• Intraparenchymal Haemorrhage
• Intraventricular Haemorrhage
(Presence of blood clot in the
Signs and Symptoms:
The common clinical manifestations of stroke are as
Numbness and weakness of face, legs and arms,
difficulty in speaking or comprehending speech, confusion, loss of balance,
dizziness, vomiting, severe headache, difficulty in walking, hemiplegis,
muscular weakness of face, altered vision, smell and taste, ptosis- drooping of
eyelids, weakness of muscles of eye, reduction in reflexes such as gag, pupil
reactivity to light and swallow, nystagmus, difficulty in maintaining balance,
weakness of sternocleidomastoid muscles, difficulty in turning head, inability
to protrude tongue out and move sidewards, vertigo.
The acronym F.A.S.T.
is very helpful in determining
whether a person is experiencing a stroke or not.
Ask the person to smile
Ask him to lift both the arms
Ask the person to repeat a sentence or phrase
Call medical emergency in case the person has the above
Depending upon the type of stroke the pharmacologic
For ischemic stroke tissue plasminogen activator
(tPA) and antiplatelets agents are used and the treatment of hemorrhagic stroke
is based on controlling the intracranial pressure and blood pressure.
Treatment of Ischemic Stroke:
The most preferred IV tPA agent is alteplase. It has been
approved by FDA for its efficacy in treating ischemic stroke.
The most authentic drug for the treatment of
ischemic stroke is aspirin. Within 24 to 48 hours of stroke aspirin therapy
should begin. Ticlopidine is known to produce aspirin- like effects.
Oral warfarin and infusions of heparin can also be
Osmotic agents such as intravenous mannitol 20% and
potent sterods like dexamethasone 4 mg intravenous is given to control cerebral
Secondary Prevention of Ischemic Stroke:
Secondary management of ischemic stroke is important
and involves the following points:
Controlling blood pressure
Controlling cholesterol levels, particularly
lowering LDL levels Statins are effective in lowering cholesterol levels.
Fibrates and niacin are also helpful in controlling triglyceride levels.
Treatment of Hemorrhagic Stroke:
The annual incidence rate of hemorrhagic stroke is
about 15 percent. The pharmacologic treatment of hemorrhagic stroke is quite
limited, however following steps:
Find out the cause of bleeding
Control blood pressure
Discontinue any medication that might cause
Take steps to control intracranial pressure.
Ventriculostomy can be done to remove collected blood from the brain.
Decompressive craniotomy can also be done.
Since subarachnoid hemorrhages
are caused mainly by aneurysm, therefore surgery the treatment of choice.
Secondary Prevention of Intracerberal Hemorrhagic Stroke:
The predisposing factors of recurrence of
intracerebral hemorrhagic stroke are:
Anticoagulation therapy post intracerebral
Location of previous hemorrhage
Finally, it can be concluded that
stroke is a time-sensitive condition irrespective of its type. Though the
pharmcotherapeutic choices are limited, but they are effective in mitigating
both the complications involved and the recurrence of the stroke.
1.Pharmacologic Management of Stroke - Shari N. Allen, assistant professor of Pharmacy Practice
in Philadelphia College of Osteopathic Medicine School of Pharmacy, Georgia; US Pharmacist 2012.