F (face)- weakness or drooping, crooked smile, sudden loss of vision in one or both eyes
A (arms) - weak or drooping arm
S (speech) - slurred or inability to understand or be understood; inability to speak
T (time) - 4-5 minutes without oxygen causes brain cell death (IRREVERSIBLE)
NIH Stroke Scale
Risk Factors
Controllable/Treatable Risk Factors
1. High Blood Pressure (140/90 or higher) - most important risk factor for stroke
2. Tobacco use - major risk factor
3. Diabetes mellitus
4. Carotid or artery disease or peripheral artery disease
5. Atrial fibrillation
6. Other heart diseases - coronary heart disease, dilated cardiomyopathy, heart valve disease, congenital heart defects, etc.
7. Transient ischemic attacks (TIA) - mini-strokes, which are warning signs of potential major stroke - patients with TIA's should be on antiplatelet regimen (i.e. aspirin, plavix, or aspirin + dipyridamole)
8. Elevated red blood cell count - can be treated with blood thinners or removing excess red blood cells
9. Sickle cell disease
10. Elevated Cholesterol
11. Physical Inactivity or Obesity
12. Excessive alcohol intake
13. Certain illicit drugs (IV drug abuse, cocaine)
Uncontrollable Risk Factors
1. Increasing age
2. Sex (gender) - more common in men
3. Family history
4. Prior stroke or heart attack - increases risk
Acute Management of Ischemic Stroke
Before any treatment, hemorrhagic stroke must be ruled out by CT scan
Any thrombolytic treatment must be initiated within three (3) hours of onset of stroke symptoms (i.e. tPA)
1. tPA - total dose (recommended): 0.9mg/kg (maximum dose should not exceed 90mg) infused over 60 minutes.  Load with 0.09mg/kg (10% of the 0.9mg/kg dose) as an IV bolus over 1 minute, followed by 0.81mg/kg (90% of the 0.9mg/kg dose) as a continuous infusion over 60 minutes.  Heparin should not be started for 24 hours or more after starting alteplase (tPA) for stroke
2. Aspirin 300mg should be given as soon as possible after the onset of stroke symptoms (unless being treated with thrombolytic agents - then should be held for 24 hours after treatment with thrombolytic).  Aspirin (50-300mg) should be continued indefinitely until an alternative antiplatelet therapy is initiated
Thus far, none of the medications aimed at salvaging ischemic brain (i.e. neuroprotectors and drugs to reduce cerebral edema) have been approved for routine use
Acute Management of Subarachnoid Hemorrhagic Stroke
CT scan should be undertaken immediately if the patient has impaired level of consciousness, otherwise CT scan should be undertaken within 12 hours
Once diagnosis confimred:
1. Nimodipine 60mg every 4 hours should be initiated (unless contraindicated)
2. Anti-fibrinolytic agents and steroids should not be given
3. General supportive measures to ensure adequate hydration and oxygenation should be instituted (including pain management)
Secondary Prevention
should be initiated within 7 days of acute stroke or TIA
1. Lifestyle modifications - smoking cessation, regular exercise, modifying diet, reduced salt intake, and avoiding excess alcohol
2. Blood pressure control - if blood pressure elevated for over two weeks, should be treated to keep <140/85 in all non-diabetic patients and <130/80 in diabetic patients (first line therapy should be ACE-I or ARB +/- diuretic (usually thiazide diuretic))
3. Anti-thrombotic therapy - all post-stroke patients should be on antiplatelet therapy (i.e. aspirin 50-300mg daily, plavix, or combination of aspirin plus dipyridamole modified release (aggrenox))
4. Anti-lipid therapy - all post-stroke patient's should be initiated on Zocor 40mg daily, unless contraindicated
5. Anticoagulation therapy should not be routinely initiated, unless atrial fibrillation present
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