·       Intervention

Surgical therapy in acute ischemic stroke

Surgical decompressive therapy within 48 hours after symptom onset is

recommended in patients up to 60 years of age with evolving malignant MCA infarcts.

 

Thrombolysis by intravenous recombinant (Tissue Plasminogen Activator)

TPA

TPA is synthesized and secreted by endothelial cells. TPA and plasminogen

bind to the fibrin clot. TPA binds specially to fibrin and activates

plasminogen only at the fibrin surface. The most widely used preparation is

the single-chain form, Alteplase. Rapid clearance of TPA takes place in

humans, largely through the liver, and so the serum half life is about 4-6

minutes11.

Practical notes about thrombolysis with rTPA

rTPA should be used solely by physicians expert in acute stroke

management and interpretation of early signs of significant infarction and

intracerebral hemorrhage on brain CT.

·       Non Intervention

 

Anticoagulants

These drugs prevent blood from clotting, rather than dissolving a clot after it has formed. They are therefore technically used to prevent another stroke.

Heparin

Given by injection, heparin works immediately to prevent blood clotting. If there is a risk of bleeding from an infected or a large brain-damaged area it may not be used.

Possible side effects include:

·            Bleeding

·            Allergic reactions

·            Thrombocytopenia (too few platelets)

Warfarin (Coumadin)

Warfarin prevents formation of a blood-clotting factor by interfering with vitamin K metabolism. It takes several days to have an effect. Warfarin is frequently given along with heparin; the heparin is then discontinued when the warfarin is fully active. Warfarin can be taken by mouth, but it must be controlled within very close limits to prevent unwanted bleeding.

The dose of warfarin varies widely and is regulated by frequent blood-clotting tests. These tests are done at least weekly at the beginning of treatment because there are so many interactions that can alter its effect. Warfarin has been shown to decrease the recurrence rate of embolic stroke by 65% in patients with atrial fibrillation (a common cause of embolic stroke.)

Possible side effects include:

·            Bleeding

·            Nausea, rashes, and a variety of other uncommon reactions

Aspirin

Aspirin, in addition to its pain-relieving effect, decreases blood clotting by affecting platelets. It has proved itself able to reduce recurring heart attacks by about 25%. Its effect on embolic stroke is about the same.

Possible side effects include:

·            Bleeding

·            Stomach irritation and bleeding

·            Occasional allergic reactions