Acne Vulgaris definition, causes, aggravating factors, pathogenesis, classification, complications, treatment and management.

Ischemic stroke definition

It occurs due to blockage of blood vessel which limits the blood supply to the brain.

Ischemic stroke icd 10

I63 is the code of ischemic stroke.

Ischemic stroke risk factors 

Non modifiable risk factors

• Age
• Gender
• Family history
• Genetic predisposition
• Low birth weight

Modifiable risk factors

• Hypertension (single most important risk factor)
• Atrial fibrillation (most important and treatable risk factor)
• Diabetes mellitus
• Dyslipidemia
• Smoking
• Obesity
• Physical inactivity
• contraceptives
• Alcohol consumption

Ischemic stroke symptoms

• Sudden onset facial weakness
• Arm drift
• Abnormal speech (dysarthria)
• Numbness
• Blurred vision
• Confusion/altered conspicuousness
• Aphasia

Warning signs of stroke 

If the patient, specially those with risk factors, has developed any of these symptoms, he is mostly has developed a stroke

Ischemic stroke vs hemorrhagic stroke

Ischemic stroke is developed when a thrombus formed in a clogged cerebral artery  by atherosclerotic plaques, resulting in ischemia to the supplied area of the brain by this artery.

Hemorrhagic stroke is mainly caused by severely elevated B.P, which leads to rupture of cerebral artery, resulting in bleeding in the brain.

Ischemic stroke diagnosis

1. Clinical picture, specially patients with risk factors
2. Laboratory tests:

• CBC  to exclude infections (meningitis).
• Coagulation studies (aPTT , INR).
• CT scan.
• MRI.
• ECG (to determine whether there is atrial fibrillation or not).

Ischemic stroke treatment and management

Goals of therapy

1.    To reduce the going neurologic injury and decrease mortality and long term disability.
   
2.     To prevent stroke recurrence.

Supportive measures

• Maintain oxygen saturation > 90%.
• Volume and electrolyte correction.
• Treat hypoglycemia (<50mg/dl) or hyperglycemia (only if glucose is >200mg/dl by S.C insulin).
• Treat fever (because high body temperature is associated with increased metabolic activity).
• Treat high blood pressure.

Ischemic stroke blood pressure goal

If the patient is candidate for thrombolytic therapy treat high blood pressure if systolic B.P is > 185mmHg or diastolic is > 110mmHg.

 If the patient is not candidate for thrombolytic therapy treat high blood pressure if B.P is > 220/120mmHg.

 

Drugs used to lower B.P in those patients

Short acting parenteral agents (by I.V infusion) such as; labetalol, nicardipine or nitroprusside.

 

Risk of high blood pressure in those patients

Great risk of cerebral hemorrhage, especially if thrombolytic therapy is indicated.

Risk of lowering B.P in those patients

Compromise cerebral blood flow and expand the region of ischemia and infarction.

Reperfusion

• Tissue plasminogen activators (t-PA) are preferably used with 3.5 hours up to hours of onset of symptoms at the dose of 0.9 mg/kg over one hour.
•  Alteplase is the preferred one of t-PA and approved by most guidelines.

Summary of essential of the treatment protocol

• Onset of symptoms within 3.5-4 hours, Ct scan is performed to rule out cerebral hemorrhage, meet other inclusion and exclusion criteria then administer t-PA 0.9 mg/kg over 1 hour with 10% of dose is given as initial bolus over 1 minute.
• Avoid the use of antithrombotic (antiplatelet and anticoagulant ) therapy for 24 hours after t-PA therapy and monitor the patient response and hemorrhage.

·        Other antithrombotic therapies

-         Aspirin 300 mg/day started with 48 hours of the event and continued for 2 weeks, but never given within 24 hours of t-PA use.

-         Heparin at low doses to prevent Venus thrombo-embolism ( VTE ) 24 hours after t-PA use if the patient had suffered of any disability and have to stay at hospital for management and monitoring.

Secondary prevention of for non-cardiogenic stroke

Antiplatelet therapy: either aspirin (50-325 mg/day ) or clopidgrel 75 mg/ day or aspirin 25mg + extended release dipyridamole 200 mg twice daily.

 Secondary prevention of for cardiogenic stroke

       Warfarin ( at a dose maintain INR of 2.5 ) or apixaban 5 mg twice daily.  

        Dabigatran or rivaroxaban also can be used. 

 Post stroke management 

All patients should reduce risk factors of stroke to prevent the recurrence of stroke as follows:

• Management of hypertension: antihypertensive therapy ( best combination is diuretics + ACEIs or ARBs ).
• Use of Statins ( to manage hyperlipidemia ).
• Management of diabetes mellitus.
• Management of obesity.

References

• Pharmacotherapy principles and practice 4 edition
• Pubmed
•  https://www.icd10data.com/ICD10CM/Codes/I00-I99/I60-I69