What is the treatment plan for a 67-year-old healthy female diagnosed with a stroke in the Emergency Room (ER) following vision changes?

From the Guidelines

For a 67-year-old healthy female diagnosed with stroke in the ER following vision changes, the treatment plan should prioritize immediate evaluation and treatment with intravenous rtPA (0.9 mg/kg; maximum 90 mg) if the stroke occurred within 3 hours of onset and there are no contraindications, as this has been shown to improve outcomes and reduce death or disability from stroke 1. The patient's treatment should focus on both acute management and secondary prevention.

• Initially, the patient should receive urgent evaluation and treatment to determine the cause of the symptoms and whether the patient can be treated with intravenous rtPA.
• The management of the patient should include measures to protect the airway, breathing, and circulation (life support), especially among seriously ill or comatose patients, and an elevated blood pressure should be lowered cautiously.
• Intravenous administration of rtPA is strongly recommended for treatment of carefully selected patients who can receive the medication within 3 hours of onset of stroke, with safe use requiring adherence to NINDS selection criteria, close observation, and careful ancillary care 1.
• Comprehensive stroke unit care, including comprehensive rehabilitation, can be given to a broad spectrum of patients, and subsequent treatment in the hospital should include measures to prevent or treat medical or neurological complications of stroke.
• An evaluation to determine the most likely cause of the patient’s stroke should lead to institution of medical or surgical therapies to lessen the risk of recurrent stroke, and rehabilitation and plans for care after hospitalization also are important components of acute management of patients with stroke 1.
• Aspirin can be administered within the first 48 hours because of reasonable safety and a small benefit, and the patient will need comprehensive rehabilitation including physical, occupational, and speech therapy as appropriate for any deficits.
• Carotid imaging should be performed to assess for stenosis, which might require surgical intervention if significant, and cardiac evaluation including echocardiogram and extended cardiac monitoring for at least 14 days is necessary to rule out cardioembolic sources, particularly atrial fibrillation which would necessitate anticoagulation therapy.
• Lifestyle modifications including Mediterranean diet, regular exercise, smoking cessation if applicable, and limiting alcohol consumption are essential components of recovery and prevention, and regular follow-up with a neurologist is recommended at 1,3,6, and 12 months post-stroke to monitor recovery and medication effectiveness.
• The more recent guidelines from 2007 support the development of an organized protocol and stroke team to speed the clinical assessment, the performance of diagnostic studies, and decisions for early management, and the use of a stroke rating scale, such as the NIHSS, to provide important information about the severity of stroke and to influence decisions about acute treatment 1.

From the FDA Drug Label

Systemic exposures of unbound apixaban in male and female rats at the highest dose tested (600 mg/kg/day) were 2 and 4 times, respectively, the human exposure 14 CLINICAL STUDIES 14. 1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation ARISTOTLE Evidence for the efficacy and safety of apixaban was derived from ARISTOTLE, a multinational, double-blind study in patients with nonvalvular AF comparing the effects of apixaban and warfarin on the risk of stroke and non-central nervous system (CNS) systemic embolism.

The treatment plan for a 67-year-old healthy female diagnosed with a stroke in the Emergency Room (ER) following vision changes is not directly addressed in the provided drug label.

• The label discusses the use of apixaban for reducing the risk of stroke and systemic embolism in nonvalvular atrial fibrillation, but does not provide information on the treatment of acute stroke.
• The study results show that apixaban is effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, but this does not necessarily apply to the treatment of acute stroke.
• No conclusion can be drawn from the provided information regarding the treatment plan for this patient. 2

From the Research

Treatment Plan for Acute Ischemic Stroke

The treatment plan for a 67-year-old healthy female diagnosed with a stroke in the Emergency Room (ER) following vision changes typically involves immediate administration of tissue plasminogen activator (tPA) thrombolytic therapy, provided there are no contraindications 3.

Key Considerations

• The time window for tPA thrombolytic therapy has been extended from 3 to 4.5 hours after ischemic stroke onset, allowing more patients to benefit from this treatment 3.
• Healthcare providers should assess for any neurological contraindications to fibrinolytic therapy, including history of intracranial hemorrhage, significant closed head or facial trauma, uncontrolled hypertension, or ischemic stroke within the past 3 months 3.
• A nationwide quality improvement program for acute ischemic stroke has been associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes 4.

Treatment Options

• tPA thrombolytic therapy is the primary treatment for acute ischemic stroke, with benefits being time-dependent 4, 5.
• Antithrombotic therapy, including antiplatelet drugs such as aspirin, plays a crucial role in secondary prevention following ischemic stroke 6.
• Dual antiplatelet therapy (DAPT) using aspirin and clopidogrel may be effective for a limited period (21 days to 3 months) following acute ischemic stroke or transient ischemic attack 6.

Important Factors

• Door-to-needle (DTN) times should be minimized to ensure timely administration of tPA thrombolytic therapy 4.
• Patients with acute ischemic stroke should be evaluated promptly, and treatment options should be considered on a case-by-case basis, taking into account individual risk factors and contraindications 5, 7.