Modern view into ischemic stroke from young doctor

1. Ahmad Aqeel
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2.  Stroke is a collective term for several types of cerebrovascular accident: ischemic
stroke (also known as cerebral infarction), hemorrhagic stroke (bleeding in the
brain), venous infarction, subarachnoid hemorrhage (bleeding into the space
between the inner and middle layers of tissue covering the brain) .
 Ischemic stroke is the death of an area of brain tissue as a result of insufficient
blood and oxygen supply to the brain due to a blocked artery.

3.  Atherothrombotic ischemic stroke - this
stroke occurs due to blockage of a blood
vessel in the brain by a blood clot.
 Thromboembolic ischemic stroke -
develops when a blood vessel is blocked
by a thrombus from a peripheral
source. A blood clot often forms in the
heart.

4.  General events and Blood pressure management
1. When treating ischemic stroke, it is customary not to reduce blood pressure
quickly if it is high, especially in the first days of the disease. Low blood
pressure should be increased - this is done by doctors; do not give the patient
any medications on your own. So Keeping blood pressure within a safe range is
crucial to prevent further damage to blood vessels in the brain.
2. Uncontrollable, severe vomiting is a common problem in the period immediately
after a stroke, especially when the basilar artery is affected. This creates
problems in the patient's nutrition. If vomiting does not stop, or there is
dysphagia, then a feeding tube is inserted. The lack of electrolytes is
compensated for by infusion therapy. The airway should be closely monitored.

5.  Thrombolytic therapy is the only therapy for ischemic stroke in the acute period
 No more than 4.5 hours It's administered intravenously should pass from the onset of the first
symptoms of a stroke to the administration of a thrombolytic, so prompt hospitalization is important.
 there are currently five generations of thrombolytics:
1. The first thrombolytics are natural substances that convert plasmagen into plasmin, thereby
causing active bleeding. These ingredients are isolated from the blood. This group of drugs is rarely
used, as severe bleeding is possible. This generation includes: Fibrinolysin, Streptokinase,
Urokinase, Streptodecase, Thromboflux.
2. The second generation are substances obtained based on the achievements of genetic engineering
using bacteria. This generation of drugs has been well studied and has virtually no side effects. Act
directly on blood clots. This generation includes: Alteplase, Actilyse, Prourokinase, Gemaz.
Purolase, Metalise .
3. Third generation - these drugs are able to quickly find a blood clot and act on it for a longer period
of time. Most effective in the first three hours: Reteplase, Tenecteplase, Lanoteplase, Antistreplase,
Antistreptolase.
4. Fourth generation - these drugs are in development and are characterized by a rapid and intense
effect on the blood clot. Insufficiently studied.
5. The fifth generation is a combination of natural and recombinant active substances.

6.  Anticoagulants prevent the formation of fibrin filaments and thrombus formation, help stop the
growth of already formed blood clots, as well as the effect of endogenous fibrinolytic enzymes on
blood clots
 Anticoagulants (heparin and indirect anticoagulants) are prescribed only when the doctor’s
instructions will be followed and it is possible to monitor blood clotting
 Direct coagulants : heparin and its derivatives, direct thrombin inhibitors, as well as selective
inhibitors of factor X ( Stewart-Prower Factor - one of the blood clotting factors).
 Indirect anticoagulants :
1. Vitamin K antagonists: phenindione (Phenilin), warfarin (Warfarex), acenocoumarol
(Sincumar);
2. Heparin and its derivatives: heparin, antithrombin III, dalteparin (Fragmin), enoxaparin
(Anfibra, hemapaxan, Clexane, Enixum), nadroparin (Fraxiparin), parnaparin (Fluxum),
sulodexide (Angioflux, Vessel Due F), bemiparin (Cibor);
3. Direct thrombin inhibitors: bivalirudin (Angiox), dabigatran etexilate (Pradaxa);
4. Selective factor X inhibitors: apixaban (Eliquis), fondaparinux (Arixtra), rivaroxaban
(Xarelto).

7.  The administration of antiplatelet agents improves the passage of fluid in the brain tissue and
prevents the development of acute disturbances in the blood supply to the brain
 Antiplatelet agents prevent platelets from sticking together, thereby preventing the formation of
blood clots.
 Classification of antiplatelet agents by mechanism of action:
1. aspirin, indobufen, trifluse (stop the action of cyclooxygenase-1, COX-1);
2. ticlopidine, clopidogrel, prasugrel, ticagrelor, cangrelor (stop the functioning of the ADP
receptor P2Y12 on platelet membranes);
3. abciximab, monofram, eptifibatide, tirofiban; xymelofiban, orbofiban, sibrafiban, lotrafiban
and others (glycoprotein (GP) Iib/IIIa antagonists);
4. dipyridamole and triflusal (cAMP phosphodiesterase inhibitors);
5. iloprost (adenylate cyclase enhancer);
6. ifetroban, sulotroban and others (suppress the TXA2/PGH2 receptor);
7. atopaxar, vorapaxar (antagonize the AR receptor (protease activated receptors) of thrombin).
 Aspirin is a commonly used drug in this group. If anticoagulants are contraindicated, then
antiplatelet agents can be used.
 A recent study found that patients who took tirofiban (aggrastat) recovered better from stroke
without large or medium vascular obstruction of the head than those who took aspirin

8.  Carotid endarterectomy is a prophylactic surgical procedure performed to remove
atherosclerotic plaque from the arteria carotis communis (common carotid artery).
 When a cerebellar stroke develops with compression of the brain stem, in order to
save the patient’s life, a surgical operation is performed to relieve intracranial
pressure in the posterior cranial fossa.

9.  Decongestant therapy
There are different and quite opposite opinions regarding the use of corticosteroids
for ischemic stroke, but doctors still actively use them to reduce cerebral edema:
they prescribe dexamethasone 10 mg intravenously or intramuscularly, then 4 mg
intravenously or intramuscularly every 4-6 hours.
 Osmotic agents . Mannitol - increases plasma osmolarity, thereby fluid from
tissues, including from the brain, moves into the bloodstream, creating a
pronounced diuretic effect, and a large amount of fluid is removed from the body.
Cancellation can have a rebound effect.
 Anticonvulsants
They must be prescribed for the development of ischemic stroke with epileptic
seizures.

10.  Rehabilitation measures begin in the early period of the disease and continue
after discharge from the hospital. They include not only drug treatment, massage,
physical therapy, speech therapy classes, but also require the involvement of other
specialists in psychological, social and labor rehabilitation.
 Along with the restoration of impaired functions, rehabilitation includes:
1. prevention of post-stroke complications;
2. prevention of recurrent strokes.
 The duration of rehabilitation is determined by the timing of restoration of
impaired functions. Recovery of motor functions occurs mainly in the first 6
months after a stroke. During this period, intensive motor rehabilitation is most
effective. Rehabilitation treatment for patients with aphasia should be longer and
carried out during the first 2-3 years after a stroke.

11. Thank youuuu ))))