Recognize signs of acute stroke, risk factors for secondary stroke

Chicago-Ophthalmologists should know the signs of an acute stroke and treat as a medical emergency, according to Valerie Biousse, MD, associate professor of ophthalmology and neurology, Emory University School of Medicine, Atlanta.

Acute stroke, also known as a “brain attack,” needs to be diagnosed quickly and the patient should be referred to a stroke team in a hospital for immediate intervention, Dr. Biousse explained during a session on therapeutic neuro-ophthalmology during the subspecialty day meeting on Saturday.

Patients may exhibit certain symptoms, including sudden weakness or numbness, usually on one side of the body, sudden difficulty speaking, sudden difficulty walking, sudden loss of vision, and sudden severe headache.

Treatments for acute ischemic stroke include:

• Intravenous tissue plasminogen activator (tPA), which is the only FDA-approved treatment for this indication. The therapy will increase the chances of a good recovery by 30% to 50%. Its drawbacks are that it must be administered within 3 hours of the first clinical sign of stroke. In addition, it should be given by a stroke expert.

• Intra-arterial (IA) thrombolysis, which is not approved by the FDA. It can be administered within 6 hours of initial stroke symptoms but only by an interventional neuroradiologist.

• Acute anticoagulation, although there is a high risk of intracranial bleeding.

• Acute aspirin therapy.

Benefits in terms of functional outcomes have been limited with IA thrombolysis and aspirin therapy, she noted.

The real gains can be seen with the identification of secondary stroke risk factors and prevention, Dr. Biousse said. Secondary risk factors that can be modified are blood pressure, LDL levels (chloresterol), and smoking. Physicians may consider antiplatet agents for secondary stroke prevention, including aspirin, aspirin plus extended-release dipyridamole, and clopidogrel. However, aspirin should not be used with clopidogrel in secondary prevention of individuals at high risk for transient ischemic attack or stroke, she noted.

Oral anticoagulation is recommended for cardioembolic ischemia. Patients with symptomatic carotid stenosis may benefit from carotid endarterectomy that is performed by an experienced surgeon or may benefit from angioplasty/stenting.

For ocular stroke, treatments involve reduction of IOP, vasodilators, and antithrombotic agents. IA thrombolysis is an invasive procedure that has also been utilized, although it is not clear what timeframe is necessary from symptom onset. An experienced interventional neuroradiologist is needed and there is a risk of complications, Dr. Biousse said.