Safety of Chlorpromazine in Stroke Patients
Chlorpromazine is not recommended for stroke patients due to increased risk of adverse outcomes, including a substantially higher risk of ischemic stroke compared to other antipsychotics. 1
Risk Assessment and Evidence
The use of chlorpromazine in stroke patients raises significant safety concerns based on available evidence:
A retrospective cohort study found that chlorpromazine was associated with a 3.47 times higher risk of ischemic stroke compared to risperidone, with even higher risk (HR = 3.60) when used for longer than 150 days 1
The American Heart Association/American Stroke Association guidelines explicitly state that neuroprotective agents, including phenothiazines like chlorpromazine, are not recommended for treatment of patients with acute ischemic stroke outside of a research setting 2
Multiple clinical trials of putative neuroprotective agents have produced negative or disappointing results, with some studies showing that treated patients had poorer outcomes or unacceptable rates of adverse experiences 2
Hemodynamic Concerns
Chlorpromazine poses particular risks for stroke patients due to its cardiovascular effects:
The medication can cause significant hypotension, which may worsen cerebral perfusion in stroke patients 3
Even when administered at controlled rates (1 mg/min), chlorpromazine has been shown to decrease mean arterial pressure, which could be detrimental in stroke patients where blood pressure management is critical 3
The American Heart Association recommends careful blood pressure management in stroke patients, and chlorpromazine's hypotensive effects could interfere with these goals 4
Extrapyramidal Side Effects
Chlorpromazine is known to cause significant extrapyramidal side effects (EPS), which could complicate neurological assessment and recovery in stroke patients 5
These side effects may be mistaken for neurological deterioration related to the stroke itself, complicating clinical management
Current Research Status
While some recent research has investigated potential neuroprotective effects:
A 2019 study examining low-dose chlorpromazine plus promethazine in acute ischemic stroke found no significant improvement in functional outcomes compared to standard care 6
The RICHES trial (2021) is investigating chlorpromazine and promethazine for potential neuroprotection in acute ischemic stroke, but results are not yet available and this remains experimental 7
Alternative Approaches for Stroke Management
For management of stroke patients requiring sedation or treatment of agitation:
Short-acting medications like lorazepam are recommended for seizures in stroke patients 2
The Canadian Stroke Best Practice Recommendations advise against prophylactic use of anticonvulsant medications in stroke patients, noting potential harm with negative effects on neural recovery 2
Conclusion
Based on current evidence, chlorpromazine should be avoided in stroke patients due to its association with increased risk of ischemic stroke, potential to cause hypotension, and extrapyramidal side effects that could complicate neurological assessment. If sedation or antipsychotic effects are needed in stroke patients, safer alternatives with less impact on blood pressure and lower stroke risk should be considered.