Stroke ischaemic/haemorrhagic

Another condition in which energy stress plays a role in disturbance of neural activity is stroke. In stroke, either haemorrhagic or ischaemic, the oxygen supply to parts of the brain is reduced. Since ATP generation is totally aerobic in neurones, this results in complete failure of ATP generation. 

Ischaemic and haemorrhagic strokes are identified by CT scan within 24—48 hours of a stroke, not by clinical signs and symptoms. However, seizures, nausea, vomiting and headache may increase the clinical likehood of haemorrhagic stroke. Haemorrhagic strokes must not be treated with any anticoagulants (e.g. aspirin) in the acute phase, whereas this is recommended for patients with ischaemic stroke. 

Thrombolysis can be considered for ischaemic stroke but ideally needs to be given within 3 hours of the stroke. There are strict guidelines which must be adhered to to maximise benefit and minimise harm from this intervention (e.g. haemorrhagic stroke must be excluded). Aspirin 300 mg orally or rectally should be given as soon as possible after the diagnosis of ischaemic stroke has been made. Many centres reduce this dose to 75 mg daily after two weeks. However, aspirin treatment should be not be initiated until 24 hours after thrombolysis (Royal College of Physicians, 2004). 

Predictors of risk of intracerebral haemorrhage in patients with a history of TIA or minor ischaemic stroke. Journal of Neurology, Neurosurgery and Psychiatry 77 92-94... 

The calcium channel blocking drugs may prove to be very useful in the treatment of patients following acute stroke. In particular, nimodipine has been found to have selective actions on cerebral vascular smooth muscle without affecting systemic arterial pressure [16]. After intravenous administration, nimodipine increases hemispheric cerebral blood flow in patients with acute ischaemic stroke [235]. A placebo-controlled double-blind trial has shown that nimodipine significantly decreases the occurrence of severe neurologic deficits from spasm alone in patients who have had subarachnoid haemorrhage [236],... 

Derex, L. and N. Nighoghossian, Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke an update. J Neurol Neurosurg Psychiatry, 2008. 79(10) p. 1093-9. 

Brekenfeld C, Remonda L, Nedeltchev K et al (2007) Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke assessment of 294 patients treated with urokinase. J Neurol Neurosurg Psychiatry 78 280-285... 

Patients with acute ischaemic stroke treated with streptokinase have an increased risk of early death due to cerebral haemorrhage if they are also given aspirin. 

Cardiovascular A meta-analysis and systemic review were performed to ascertain the relationship between prior warfarin use with subtherapeutic international normalized ratio (INR) and outcome after intravenous or intraarterial thrombolytic therapy in acute ischaemic stroke patients The outcomes were symptomatic intracranial haemorrhage, modified Rankin scale score and mortality. The risk of symptomatic intracranial haemorrhage after thrombolytic therapy was increased in patients using warfarin with subtherapeutic INR levels. However, there was no association between prior warfarin therapy and worsened fxmctional outcome or all-cause death. 

Haematologic Intravenous administration of recombinant tissue plasminogen activator (rtPA), also known as alteplase, is a common component of ischaemic stroke management, but its use is associated with intracranial haemorrhage in 6.4% of patients. A 51-year-old woman who had received IV rtPA for acute left middle cerebral artery thromboembolism later presented with subarachnoid haemorrhage from an acutely ruptured anterior communicating artery aneurysm. The patient xmderwent mechanical thromboembolectomy of the left middle cerebral artery occlusion with recanalization followed by coil embolization of the aneurysm, but she did not improve neurologjcally and ultimately died (32). ... 

Drug-drug interactions The influence of statins on outcomes of IV thrombolysis in ischaemic stroke is controversial. A case-control study and meta-analysis determined that statin pretreatment may increase the risk of symptomatic intracranial haemorrhage in patients receiving IV rt-PA however, it did not influence the 3-month outcome... 

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