Acute Ischemic Stroke Flashcards
What are some deficits experienced after a stroke? (5)
Hemiparesis
Cognitive decline
Depression
Inability to ambulate without assistance
PTSD
What are some modifiable COMORBIDITY risk factors of stroke?
HTN
Diabetes
Dyslipidemia
Arrhythmias
Carotid stenosis
Sickle cell disease
What are some modifiable BEHAVIORAL/MEDICATION risk factors of stroke? (3/2)
Cigarette smoking
Physical inactivity
Obesity
Oral contraceptives
Postmenopausal hormonal therapy
(All hormonal therapy)
What tool is used to assess ischemic stroke risk?
CHA2DS2-VASc Score
Define ischemic stroke
Brain injury due to blood loss to a specific area from atherosclerotic rupture or cardioembolism.
What are some considerations for diagnosing stroke?
Time of sx onset
Sudden onset of focal neurological deficit (weakness, sensory loss, dysphasia [think facial droop])
UNILATERAL
What TOOL can be used for diagnosis of stroke? What score indicates a minor stroke? What score indicates a severe stroke?
National Institutes for Health Stroke Scale (NIHSS)
<4 = minor stroke
>20 = severe stroke
What neurological imaging is used for ischemic stroke diagnosis? (2)
Non-contrast head CT scan - rule out hemorrhage
MRI - detects early ischemic changes
What are some common MIMICS of ischemic stroke?
Neurologic (COMMON) - seizure, migraine, brain processes, encephalopathy, vertigo, neuropathy, amnesia
Metabolic - hypo/hyperglycemia, hyponatremia, hepatic encephalopathy, drug OD
Psychiatric - conversion disorder, malingering
If a stroke is identified within 4.5 hr of sx onset, what is the treatment procedure?
- Fibrinolytics
- +/- Thrombectomy
What are some absolute contraindications of using IV fibrinolytics in stroke?
<18 yo
Ischemic stroke/intracranial surgery/head trauma < 3 months ago
GI malignancy <21 days ago
Enoxaparin within 24 hrs
DOACs within 48 hrs
Infective endocarditis
Intracranial/axial neoplasm
Unclear time of onset
Current intracranial/subarachnoid hemorrhage
Low PLT, high INR, aPPT > 40s
Aortic arch dissection
What are some SOFT contraindications for fibrinolytic use in stroke?
Seizure - use if corrected
Low or high (500+) BG = use if corrected
Recent trauma or surgery = if not involving head, weigh risk of potential bleeding
What are two IV fibrinolytics that may be used in stroke? What are the doses (mg/kg) and t1/2?
- Alteplase - bolus + infusion
DOSE: 0.9 mg/kg
T1/2 = 5 mins - Tenecteplase* - IV push
DOSE: 0.25 mg/kg
T1/2 = 20 mins
(Tenecteplase = 15x more fibrin specificity)
IV fibrinolytics cannot be given until BP is controlled. For BOLUS, BP must be <________ and for INFUSION BP must be <___________
Bolus: <185/110
Infusion: <180/105
When is permissive HTN allowed in stroke patients?
If pt is excluded from use of fibrinolytics, then BP not corrected until >220/110
What are some first line antihypertensives to use to control BP before using IV fibrinolytics?
Labetalol
Nicardipine (use if HR <55)
When could tenecteplase potentially be MORE beneficial compared to alteplase?
If the stroke is from a LARGE VESSEL OCCLUSION
IV fibrinolytics can cause complications like symptomatic ICH or angioedema. What should you do to resolve these?
Symptomatic ICH: d/c alteplase, cryoprecipitate 10U, anti fibrinolytics
Angioedema: maintain airway, hold any ACEi, Methylprednisolone, diphenhydramine, ranitidine, epinephrine (INTUBATE)
After use of fibrinolytics, we can consider thromectomy for what kind of stroke?
Used for large vessel occlusion
What should be monitored for 24 hrs after fibrinolytic use?
Check for NEUROLOGIC DECLINE and BLOOD PRESSURE
What medications should be given to a stroke patient AFTER fibrinolysis & sx resolution?
High-dose statin
Antiplatelet (aspirin for all, dual for low NIH stroke x21 days OR pts with intracerebral stent)
DVT prophylaxis
What are some secondary stroke prevention tactics? (7)
Lifestyle/Nutrition
Smoking cessation
Limit alcohol
Counsel on substance abuse
Hypertension control
Dyslipidemia control
Diabetes control
