What are the differences in treatment approaches for cerebral vascular disease (CVD) infarct (ischemic stroke) versus CVD bleed (hemorrhagic stroke)?

Treatment Approaches for CVD Infarct vs. CVD Bleed

The treatment approaches for ischemic stroke (CVD infarct) and hemorrhagic stroke (CVD bleed) are fundamentally different, with ischemic stroke focusing on reperfusion strategies and antithrombotic therapy, while hemorrhagic stroke management prioritizes blood pressure control and avoidance of anticoagulation.

Acute Management of Ischemic Stroke (CVD Infarct)

Initial Assessment and Thrombolytic Therapy

• Intravenous recombinant tissue plasminogen activator (IV r-tPA) is strongly recommended for patients with acute ischemic stroke if treatment can be initiated within 3 hours of symptom onset 1
• IV r-tPA may be considered if treatment can be initiated between 3-4.5 hours of symptom onset, though with a lower level of recommendation 1, 2
• IV r-tPA is contraindicated beyond 4.5 hours from symptom onset 1
• Standard dose of IV r-tPA is 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes 3

Endovascular Interventions

• For patients with large vessel occlusion (LVO), mechanical thrombectomy may be considered, especially when IV thrombolysis is contraindicated or ineffective 1
• Intraarterial (IA) thrombolysis may be considered for patients with acute ischemic stroke within 6 hours of symptom onset who have contraindications to IV r-tPA 1
• Neuroimaging is crucial to confirm diagnosis and guide treatment decisions, typically using non-contrast CT and CT angiography to identify vessel occlusions 1

Antithrombotic Therapy

• Early aspirin therapy (160-325 mg within 48 hours) is recommended for patients with acute ischemic stroke who are not receiving thrombolysis 1
• Therapeutic anticoagulation is not recommended in the acute phase of ischemic stroke and is inferior to antiplatelet therapy 1
• For patients with restricted mobility, prophylactic-dose low-molecular-weight heparin (LMWH) is preferred over unfractionated heparin (UFH) for venous thromboembolism prophylaxis 1

Blood Pressure Management

• Permissive hypertension is generally allowed in acute ischemic stroke unless the patient is receiving thrombolytic therapy 1
• For patients eligible for thrombolytic therapy, blood pressure should be maintained below 185/110 mmHg before treatment and below 180/105 mmHg during and after treatment 1

Acute Management of Hemorrhagic Stroke (CVD Bleed)

Initial Management

• Immediate cessation of all antithrombotic medications is essential 1
• Aggressive blood pressure control is recommended, unlike in ischemic stroke where permissive hypertension may be beneficial 1
• Neurosurgical consultation should be obtained for evaluation of potential surgical intervention, especially for large hematomas with mass effect 1

Prevention of Complications

• Prophylactic-dose subcutaneous heparin (UFH or LMWH) should be started between days 2 and 4 after intracerebral hemorrhage in patients with restricted mobility 1
• LMWH is preferred over UFH for venous thromboembolism prophylaxis 1
• Elastic compression stockings are not recommended for venous thromboembolism prophylaxis 1

Secondary Prevention

For Ischemic Stroke

• Long-term antiplatelet therapy is recommended for non-cardioembolic ischemic stroke 1
• Options include aspirin (75-100 mg daily), clopidogrel (75 mg daily), aspirin/extended-release dipyridamole (25 mg/200 mg twice daily), or cilostazol (100 mg twice daily) 1
• Clopidogrel or aspirin/extended-release dipyridamole is preferred over aspirin alone 1
• For patients with atrial fibrillation, oral anticoagulation is recommended over antiplatelet therapy 1
• Dabigatran 150 mg twice daily is suggested over vitamin K antagonists in patients with atrial fibrillation 1

For Hemorrhagic Stroke

• Long-term antithrombotic therapy for prevention of ischemic stroke is generally not recommended after primary intracerebral hemorrhage 1
• Exceptions may include patients at relatively low risk of recurrent hemorrhage but high risk of thromboembolic events 1
• Aggressive blood pressure control is essential for preventing recurrent hemorrhagic stroke 1

Key Differences in Approach

• Reperfusion vs. Hemostasis: Ischemic stroke treatment focuses on restoring blood flow through thrombolysis or thrombectomy, while hemorrhagic stroke management aims to prevent further bleeding 1
• Antithrombotic Therapy: Antiplatelet or anticoagulant medications are a mainstay of ischemic stroke treatment but are contraindicated in hemorrhagic stroke 1
• Blood Pressure Management: Permissive hypertension may be allowed in ischemic stroke (unless receiving thrombolysis), while aggressive blood pressure lowering is crucial in hemorrhagic stroke 1
• Timing of VTE Prophylaxis: Earlier initiation of prophylactic anticoagulation in ischemic stroke compared to delayed initiation (days 2-4) in hemorrhagic stroke 1

Common Pitfalls to Avoid

• Administering thrombolytics to patients with hemorrhagic stroke, which can be catastrophic 1
• Delaying thrombolytic therapy in eligible ischemic stroke patients, as time to treatment is critical for outcomes 1, 2
• Initiating therapeutic anticoagulation too early after ischemic stroke in patients with atrial fibrillation (generally wait 1-2 weeks) 1
• Failing to control blood pressure adequately in hemorrhagic stroke patients 1
• Using elastic compression stockings for VTE prophylaxis in hemorrhagic stroke patients, which is not recommended 1