What are the types of strokes and current stroke management guidelines?

From the Guidelines

There are two main types of strokes: ischemic strokes, which occur when blood flow to the brain is blocked by a clot, and hemorrhagic strokes, which happen when a blood vessel ruptures and bleeds into the brain, with ischemic strokes accounting for about 87% of all strokes and being treated with clot-busting medications like alteplase (tPA) if administered within 4.5 hours of symptom onset, or mechanical thrombectomy for large vessel occlusions within 24 hours, as recommended by the most recent guidelines 1.

Types of Strokes

• Ischemic strokes: occur when blood flow to the brain is blocked by a clot
• Hemorrhagic strokes: occur when a blood vessel ruptures and bleeds into the brain

Current Stroke Management Guidelines

• Ischemic strokes: treated with clot-busting medications like alteplase (tPA) if administered within 4.5 hours of symptom onset, or mechanical thrombectomy for large vessel occlusions within 24 hours 1
• Hemorrhagic strokes: require different management, often focusing on controlling blood pressure and sometimes surgical intervention
• Stroke prevention: guidelines recommend controlling risk factors including hypertension (target <130/80 mmHg), diabetes (HbA1c <7%), and cholesterol (statins for high-risk patients) 1
• Antiplatelet therapy with aspirin (81-325 mg daily), clopidogrel (75 mg daily), or combination therapy is recommended for secondary prevention in ischemic stroke 1
• Anticoagulation with direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, or dabigatran, or warfarin (target INR 2-3) is indicated for patients with atrial fibrillation 1
• Lifestyle modifications are equally important, including smoking cessation, limiting alcohol consumption, maintaining healthy weight, regular physical activity, and following a Mediterranean or DASH diet 1

Importance of Early Intervention

• Recognizing stroke symptoms using the FAST method (Face drooping, Arm weakness, Speech difficulties, Time to call emergency services) is crucial for early intervention, as every minute delay in treatment results in the loss of approximately 1.9 million neurons 1
• Early diagnosis and pre-hospital care, including public education programs and emergency transportation systems, are essential for reducing times to ED arrival and improving outcomes 1

From the FDA Drug Label

The primary endpoint was the time to first occurrence of stroke (any type) or non-CNS systemic embolism. Stroke types include:

• Hemorrhagic Stroke
• Ischemic Stroke
• Unknown Stroke Type The efficacy of XARELTO was generally consistent across major subgroups. The primary composite endpoint of time to first occurrence of stroke (any type) or non-CNS systemic embolism [HR (95% CI): 0.88 (0.74,1. 03)], but superiority to warfarin was not demonstrated.

The types of strokes mentioned are Hemorrhagic Stroke, Ischemic Stroke, and Unknown Stroke Type. Current stroke management guidelines are not explicitly stated in the provided text, but it can be inferred that the management of stroke involves the use of anticoagulants such as XARELTO and warfarin to reduce the risk of stroke and non-CNS systemic embolism in patients with nonvalvular atrial fibrillation. 2

From the Research

Types of Strokes

• Ischemic stroke: occurs when there is a loss of blood supply to the tissue, which can result in irreversible damage if blood flow is not restored quickly 3
• Hemorrhagic stroke: although not explicitly mentioned in the provided studies, it is discussed in the context of differential treatment according to etiology in the prehospital phase of stroke management 4

Current Stroke Management Guidelines

• Public education is needed to emphasize the warning signs of stroke, and patients should seek medical help immediately using emergency transport systems 3
• Therapy geared toward minimizing the damage from an acute stroke should be started without delay in the emergency room, including measures to protect brain tissue, support perfusion pressure, and minimize cerebral edema 3
• Mechanical thrombectomy within 6 hours of symptom onset should be considered the preferred treatment for patients with proximal intracranial artery occlusion, along with IV thrombolysis with recombinant tissue plasminogen activator (rtPA) within the first 4.5 hours for all patients who do not have contraindications for systemic thrombolysis 5
• Systems of care should be optimized to maximize the number of patients with acute ischemic stroke able to receive reperfusion therapy, with timely successful reperfusion being the most effective treatment for patients with acute ischemic stroke 5
• Prehospital considerations, initial evaluation, and treatment options, including thrombolysis and endovascular therapy, are critical in the management of acute ischemic stroke 6
• Intravenous thrombolysis and mechanical thrombectomy are current strategies for specific treatment of stroke in the acute phase, with a focus on shortening the delay between stroke onset and treatment and reducing the risk of symptomatic intracerebral haemorrhage 7
• The use of a "Mobile Stroke Unit" can enable delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital 4