 CEREBROVASCULAR ACCIDENT Cerebrovascular accident (CVA), or stroke, is a widespread medical condition affecting one out of every four people during their lifetime. CVA is an acute, localized injury of the central nervous system (CNS) caused by a blood vessel problem, resulting in a neurological deficit[1]. The World Health Organization definition of stroke is “rapidly developing clinical signs of focal disturbance of cerebral function, lasting for 24hours or leading to death, with no apparent cause other than that of vascular origin” [2]. A stroke can occur either when a blood vessel in the brain ruptures and bleeds, or when a blockage stops blood flow to the brain. In both cases, the interruption prevents blood and oxygen from reaching the brain tissue, resulting in damage to the affected area [3]. Stroke is now widely considered a largely preventable neurological emergency, as a major proportion of its global burden is linked to modifiable risk factors including hypertension, diabetes mellitus, tobacco use, physical inactivity, unhealthy dietary habits, and atrial fibrillation. In addition to causing acute neurological deficits, stroke often leads to persistent complications such as cognitive decline, emotional and psychological disturbances, reduced functional independence, and significant socioeconomic strain on both families and healthcare systems [4]. Advances in neuroimaging techniques have enhanced understanding of the ischemic penumbra, which refers to the area of brain tissue surrounding the infarct core that remains potentially viable if blood flow is restored promptly. This has reinforced the clinical importance of early diagnosis and rapid therapeutic intervention. The widely accepted principle of “time is brain” further emphasizes that irreversible neuronal loss progresses rapidly during untreated ischemia, highlighting the urgency of immediate management in acute stroke care [5] TYPES [6] Three types of strokes are, • Transient ischemic attack • Ischemic stroke • Haemorrhagic stroke Stroke is a neurological disorder resulting from an interruption of blood supply to the brain or bleeding within the cranial cavity. Ischemic stroke is the most common form and occurs when a cerebral artery becomes obstructed, leading to reduced blood flow and oxygen delivery to brain tissue. Haemorrhagic stroke develops when a blood vessel ruptures, causing bleeding either within the brain parenchyma or into the subarachnoid space. Ischemic strokes can be further classified according to their underlying cause, including large-vessel disease, cardio embolism, and small-vessel occlusion. Accurate classification of stroke is important for determining appropriate treatment strategies and predicting patient outcomes. SYMPTOMS The symptoms of a stroke will affect almost all body parts, in which the brain plays a significant role in monitoring. The signs of stroke depend on the lobe effects:  Frontal lobe: • Contralateral weakness • Gait-apraxia gait • Non fluent aphasia • Apathy • Mutism • Reflexes positive  Temporal lobe: • Wernick’s aphasia • Visual field defect • Learning difficulties • Memory impairment • Emotional disturbance • Kluver Bucy syndrome  Parietal lobe: • Wernick’s lesion • C/L Discriminatory sensory impairment • Ideational apraxia • Ideomotor • Gerstmann syndrome  Occipital lobe: • Visual agnosia • Contralateralhomonymous hemianopia • Visual agnosia • Visual illusions • Visual hallucinations Table no. 1: Symptoms of CVA [7] RISK FACTORS • Several risk factors contribute to the development of stroke. Non-modifiable risk factors include advanced age, male sex, family history, ethnicity, and previous stroke or TIA. Modifiable risk factors include hypertension, diabetes mellitus, dyslipidaemia, smoking, obesity, physical inactivity, atrial fibrillation, excessive alcohol consumption, and cardiovascular diseases. Among these, hypertension is considered the most important modifiable risk factor and is responsible for a substantial proportion of stroke cases worldwide. Effective management of these factors significantly reduces stroke incidence [8] • Age • Gender • Family history of stroke • Habits like smoking and drinking • Sedentary life style • Comorbid conditions (dyslipidaemia, hypertension, DM) Fig no. 1: Clinical manifestations of CVA[9] EPIDEMIOLOGY In India, stroke prevalence among the elderly is estimated at 1.1% in rural areas and 1.9% in urban areas. Stroke ranks as a leading cause of death worldwide, particularly among the elderly. It is considered the third most common cause of death after coronary heart disease and all types of cancer [10]. According to the global burden of Disease project, it estimates that the number of incident cases of stroke in India was 1,175,778 It also estimates 29.6% of all deaths worldwide (15616.1 million deaths) were caused by CVA in 2010[11]. PATHOPHYSIOLOGY  Pathophysiology of Ischemic Stroke In ischemic stroke, obstruction of a cerebral artery reduces blood flow to brain tissue. This deprivation of oxygen and glucose leads to failure of cellular energy production, causing dysfunction of ion pumps, membrane depolarization, calcium influx, and excitotoxicity. The central region of severe ischemia, known as the ischemic core, undergoes irreversible damage within minutes. Surrounding this area is the ischemic penumbra, which remains viable for a limited period and can potentially be salvaged through rapid reperfusion therapies. Cellular inflammation, oxidative stress, and apoptosis further contribute to neuronal injury [12]  Pathophysiology of Haemorrhagic Stroke Haemorrhagic stroke occurs when blood vessels rupture, resulting in bleeding within the brain tissue or subarachnoid space. The extravasated blood exerts mechanical pressure on surrounding structures and increases intracranial pressure. Blood breakdown products trigger inflammatory responses and cerebral edema, leading to secondary neuronal injury. Large hematomas may cause brain herniation and rapid neurological deterioration, making haemorrhagic stroke a life- threatening condition enquiring urgent intervention [13]  Pathophysiology of Transient ischemic attack Transient ischemic attack (TIA) results from a transient reduction in blood flow to a focal region of the brain, retina, or spinal cord, leading to temporary neurological dysfunction without permanent cerebral infarction. The most common mechanisms include embolism from cardiac or arterial sources, atherosclerotic vascular disease, and hemodynamic insufficiency. Because cerebral perfusion is restored before irreversible neuronal injury occurs, neurological deficits resolve completely. TIA is an important clinical indicator of underlying cerebrovascular disease and an increased risk of subsequent ischemic stroke [14] Fig no 2: Pathophysiology of CVA [15] DIAGNOSIS [2] Diagnosis of stroke involves obtaining. • Medical history • Physical examination • Blood test • Magnetic resonance imaging (MRI) • Computed tomography scan (CT-SCAN) • EKG • Cerebral angiogram • Carotid ultrasound • Echocardiogram • For TIA - ABCD2 SCORE COMPLICATIONS [16] • Post-stroke seizures • cognitive impairment • spasticity hemiplegic shoulder pain • wrist and hand flexion • post-stroke depression • emotional lability • mood/emotional change TREATMENT Stroke is a medical emergency that requires rapid diagnosis and prompt treatment to minimize brain injury and improve functional outcomes. Initial management includes assessment of airway, breathing, and circulation (ABC), stabilization of vital signs, blood glucose measurement, oxygen supplementation only if hypoxic, establishment of intravenous access, and urgent neuroimaging with a non-contrast CT scan or MRI to differentiate ischemic from haemorrhagic stroke. The exact time of symptom onset should be documented, and the severity of neurological deficits should be assessed using the National Institutes of Health Stroke Scale (NIHSS). Continuous cardiac monitoring, laboratory investigations, and evaluation for underlying risk factors should also be performed [5]. a) Treatment of Ischemic Stroke [17] For patients presenting within the therapeutic window and meeting eligibility criteria, intravenous thrombolysis with recombinant tissue plasminogen activator (alteplase) should be administered within 4.5 hours of symptom onset after exclusion of contraindications. In selected patients with large-vessel occlusion, mechanical thrombectomy is recommended within 6 hours and may be extended up to 24 hours in carefully selected cases based on advanced imaging criteria. Blood pressure should be maintained below 185/110 mmHg before thrombolysis and below 180/105 mmHg during the first 24 hours after treatment. Patients who are not candidates for thrombolysis should receive aspirin (160–325 mg) within 24–48 hours after stroke onset, provided intracranial haemorrhage has been excluded. In patients with minor ischemic stroke or high-risk transient ischemic attack (TIA), dual antiplatelet therapy with aspirin and clopidogrel is recommended for 21 days, followed by long-term single antiplatelet therapy. High-intensity statin therapy should be initiated unless contraindicated. Blood glucose should be maintained between 140 and 180 mg/dL, fever should be treated promptly, and adequate hydration and nutritional support should be ensured. b) Treatment of Haemorrhagic Stroke [18] Management of haemorrhagic stroke focuses on limiting hematoma expansion, reducing intracranial pressure, and preventing secondary brain injury. Blood pressure should be carefully controlled according to current guideline recommendations. Any anticoagulant therapy should be immediately discontinued and reversed using appropriate reversal agents. Management of raised intracranial pressure includes head elevation, osmotic therapy such as mannitol or hypertonic saline when indicated, adequate analgesia and sedation, and neurosurgical consultation for patients with large hematomas, cerebellar haemorrhage, hydrocephalus, or significant mass effect. Seizures should be treated if present, and supportive intensive care should be provided. • Management of Transient Ischemic Attack (TIA) [19] Patients with TIA require urgent evaluation because of the high risk of subsequent stroke. High-risk patients with minor non-cardioembolic stroke or TIA should receive dual antiplatelet therapy (aspirin plus clopidogrel) initiated within 24 hours and continued for 21 days, followed by long-term single antiplatelet therapy. Aggressive control of hypertension, diabetes mellitus, dyslipidaemia, smoking cessation, weight reduction, and treatment of carotid artery disease when indicated are essential components of secondary prevention. • Secondary Prevention of Stroke [20] Long-term prevention includes strict blood pressure control, diabetes management, lipid-lowering therapy with high-intensity statins, smoking cessation, regular physical activity, weight management, dietary modification with reduced salt and saturated fat intake, and limitation of alcohol consumption. Antiplatelet therapy is recommended for non-cardioembolic stroke, whereas anticoagulation is indicated for cardioembolic stroke caused by conditions such as atrial fibrillation, after careful assessment of bleeding risk. Carotid endarterectomy or carotid artery stenting may be considered in selected patients with significant carotid stenosis. • Rehabilitation and Supportive Care [20] Early multidisciplinary rehabilitation should begin as soon as the patient is medically stable. Physiotherapy helps improve mobility and muscle strength, occupational therapy enhances independence in daily activities, and speech and language therapy addresses dysphasia and swallowing disorders. Patients should be screened for dysphagia before oral feeding to reduce the risk of aspiration pneumonia. Deep vein thrombosis prophylaxis, prevention of pressure ulcers, bowel and bladder care, nutritional support, and psychological counselling should be incorporated into comprehensive stroke management. Long-term follow-up and patient education regarding medication adherence and lifestyle modification are essential to reduce recurrent stroke risk and improve quality of life. The management of CVA varies depending on the type of stroke, as summarized in the table. 3 [7]. TIA Ischemic stroke Haemorrhagic stroke a) In 1st 21 days: dual antiplatelet therapy (Aspirin + Clopidogrel). Later converted to single therapy. b) Thrombolytics i.e., alteplase c) T- PA (tissue plasminogen Activator) in patients with NHISS >5 d) Thrombectomy in patients with NHISS>8 e) Antihypertensives like labetalol, nicardipine etc. (BP < 185/110 mmHg) f) Thrombolytics are given or contraindicated based on bleeds, intracranial aneurysm size and neoplasm. g) Anticoagulants are avoided h) Antiplatelets are avoided in 1st 24 hours of thrombolytics later dual therapy for 21 days and single drug therapy after 21 days i) Manage hypertension and DM j) Manage ICP0 Table no. 2: Management of CVA  DRUG UTILISATION EVALUATION Drug utilization evaluation is defined as the systematic study of marketing, distribution, prescribing, and utilization of drugs within the community, with particular emphasis on the resulting medical, social and economic outcomes. It is crucial to understand the interrelationship of the different domains for optimizing rational drug use.[21] The concept originates from the broader field of drug utilization research, which was defined by the World Health Organization as the study of distribution, prescription and utilization.[22] DUE programs provide a systematic approach to identifying such problems and initiating appropriate measures through education, policy development, and interdisciplinary collaboration [23]. Drug utilization evaluation mainly focuses on: • Appropriateness of drug selection [21,23] • Dose, frequency, and duration of therapy [22,24] • Adherence to clinical guidelines and institutional policies. • Detection of drug-related problems (DRPs). • Monitoring of adverse drug reactions. • Evaluation of polypharmacy and drug interactions. • Identification of prescribing trends and patterns. According to the American Society of Health-System Pharmacists (ASHP), DUE is an authorized, structured, ongoing review of prescribing, dispensing, and medication use patterns. REDUCE TO HALF PAGE

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