Cerebrovascular disease Flashcards
What is the MC stroke?
Iscehmic (like 80%)
Next is hemoragic
Explain an ischemic stroke
Acute occlusion o an intracranial vessel that leads to decreased blood flow resulting in hypoxia and neurologic function loss.
Ischemic core vs penumbra
Ischemic core is the area of complete loss of flow = death of brain tissue within 4–10 min
Penumbra is the surrounding tissue which has only a reduction in flow and can remain viable for hours after onset of stroke
Penumbra can turn into an ischemic core (time = brain tissue)
What are the 2 pathologies that lead to ischemic stroke
- Thrombotic - likely related to ruptured atherosclerotic plaques leading to platelet activation
Associated with: HTN, DM, hyperlipidemia, carotid artery disease, alcohol consumption, and smoking - Embolic - embolus originating from extracranial source
Associated with: atrial fibrillation (MC), cardiac valve disease, MI, endocarditis and cardiomyopathy
MCC of embolic ischemic stroke
A fib
Overview of risk factors of ischemic stroke in older population that are not part of ischemic heart disease
FHx of TIA/Stroke
Risk factors of ischemic stroke in younger population
Traumatic Brain Injury (TBI)¹
Coagulopathies
Illicit drug use
cocaine
Migraines²
women, oral contraceptive use, age < 45, migraine with aura
Oral contraceptive use
Covid-19
What type of migraines a risk factor for younger patients having ischemic stroke?
Migraines with an aura
Explain the general pathophys that leads to hemorrhagic stroke and what it leads to
a spontaneous RUPTURE of a cerebral artery leads to:
cerebral ischemia resulting from loss of microvascular perfusion due to acute vasoconstriction and microvascular platelet aggregation
increased intracranial pressure
What are the two specifc patho[hys tha leads to hemmoriagic stroke
2 pathologic etiologies
- Intracerebral hemorrhage (ICH)
- Subarachnoid hemorrhage (SAH)
aneurysm, arteriovenous (AV) malformations, trauma
MCC of ICH
intracranial hemmorage
Prolonged uncontrolled HTN
Specific risk factors of hemorrhagic stroke
Advanced age
Hypertension (up to 60% of cases)
Anticoagulant use
Previous history of stroke
Alcohol abuse
Use of illicit drugs (eg, cocaine, other sympathomimetic drugs)
Stroke prevention mnemonic for average person
BE FAST
Balance
Eyes
Face
Arms
Speech
Time
seen in every stroke pretty much
Balance
Ataxia
Vertigo (rare)
Disequilibrium
Eyes
Visual loss
any type
Visual deffedts
Face
MC sign of stroke
facial droop (bells palsy is complete loss in the face, while in stroke, your forehead can move)
Arms
unilateral, weakness/sensory
Speech
dysarthria/aphasia
Time
time is brain tissue
What is the MC symptom of specifically aa hemorrhagic stroke? What are some others
Intracranial bleeding, leading to:
HA, thunderclap (MC)
N/V
seizure
syncope
AMS: LOC
What is the most important thing to know history wise for stroke?
ONSET - lets you know management
when they were last normal
What is the second most important piece of info for a stroke?
Timeline:
progression vs regression
MC stroke mimicker
hypoglycemia MC
Important med to take in mind if you think they have a stoke
anticoagulants or hypoglycemic defects
What PMH is important to know for stroke
epilepsy, drug overdose or abuse, recent trauma
Why do you intubate for 8 or lower?
They cannot protect their airway alone
What PE do you perform for suspected stroke and most important
ABC
VS
Skin
HEENT
CV
Respiratory
Neuro (most important
What is common findings of stroke on PE
ABC’s and VS
Assess LOC and determine need for airway assistance
hemorrhagic strokes often deteriorate more rapidly
Skin
petechiae, Janeway lesions¹, Osler’s nodes² (infective endocarditis)
livedo reticularis³/gangrene (cholesterol emboli)
purpura, ecchymoses (bleeding diathesis, anticoagulation)
recent surgical sites/scars (may not be able to have clot busters)
HEENT
signs of trauma
fundoscopy
papilledema (ICP)
retinopathy, retinal emboli, retinal hemorrhage (signs of predisposing conditions)
mouth - tongue laceration (indicative of seizure)
Cardiovascular
Irregular rhythm, murmur, gallop (cardiogenic emboli)
Indicating a.fib, endocarditis, other valvular diseases, cardiomyopathy, MI
Palpate carotid, radial, and femoral pulses
Assessing absence, asymmetry or irregular rate
Auscultation for carotid bruit (thrombotic etiology)
Respiratory
abnormal breath sounds, bronchospasm, fluid overload or stridor
Cranial Nerves
National Institutes of Health Stroke Scale (NIHSS - provides a quantitative measure of stroke-related neurologic deficit)
Mental status and level of consciousness
Vision - visual fields by confrontation
Motor function - arm/leg lift, facial movement
Cerebellar function - F-N, H-S
Sensory function - sharp sensation
Language (expressive and receptive capabilities) ask pt to describe an image or read sentences shown to patient
assessing ability to comprehend task and coordinate speech
Neglect - lack of awareness of disability or visual comprehension
What are the different scores for Natinonal Institute of Health Stroke Scale
0
No stroke symptoms
1-4
Minor stroke
5-15
Moderate stroke
16-20
Moderate to severe stroke
21-42
Severe stroke
What is the first thing you do for stroke and why?
Point of care glucose to r/o hypoglycemia, which could be causing the neuro deficits
What do you see in a CT w/out contrast for an ischemic stroke?
Normal
if it is hemmoragic, you will see the bleeding
What is the goal time to get a CT scan for stroke
- minutes
What does a SAH look like on CT?
loopy starfish
What happens for an ischemic stroke CT with time?
See problems with time
What do you see on hemorragic stroke CT?
Midline shift
What labs do you order for stroke?
CBC
BMP/CMP
PT/PTT/INR
Direct factor Xa activity assay
Troponin (always)
EKG w/in 10 minutes
When do you get advanced imaging for stroke and what imaging might you order?
after stabilization and treatment is initiated to look for etiology and severity of stroke damage
CTA, MRA and/or MRI of the brain
Carotid duplex US (always at some point)
Echo (if irregular cardiac rhythm)
What additional labs can you order and why?
Toxicology screen - suspected drug use (eg. cocaine)
Blood alcohol concentration (BAC) - increases risk of bleeding/stroke mimic
Lumbar puncture
indicated if high suspicion for SAH with a normal CT head
ABG - if hypoxic (avoid if considering fibrinolytic therapy)
hCG - women of childbearing age
ESR/CRP - elevated in infective endocarditis
CXR - if suspected or history of lung disease or (+)fever
EEG - suspected seizure
UA/blood cultures - if (+) fever
When do you adminster O2 or stroke?
Maintain above 94%
Why do you tell a patient to be NPO for stroke?
risk of aspiration d/t dysphagia from stroke
consult occupational therapy (for swallowing study)
swallowing has to be assessed prior to advancement of diet
Fluids - IV normal saline
If there is signs of ICP, what should the bed be at?
elevate head of bed 30°
If a patient is >100.4
acetaminophen
“PR” (rectal), IV (Ofirmev)
surface cooling¹
Evaporative cooling, Ice water immersion, Whole-body or strategic ice packing
search for cause
common causes: aspiration pneumonia, UTI
Hypothermia can worsen cerebral ischemia in all strokes
tx with warm blankets, bear hugger, warm IV fluids
When do you treat hypoglycemia or hypoglycemia?
hypoglycemia - treat if BS <60 mg/dL (class 1)
hyperglycemia - treat if BS is >180 mg/dL to a goal of between 140-180 mg/dL (class IIa)
What should you do if a patient is on an anticoagulation med and has hemorrhagic stroke
reversal agent to allow clogging
treatment for ischemic stroke
- Determine eligibility for fibrinolytic therapy (rt-PA)
Hypotension (2019 update)
IV fluids to maintain organ perfusion, although a specific goal is not provided
BP goal of SBP ≤ 185 and DBP ≤ 110 before rt-PA can be administered (class 1)
First line antihypertensives¹
IV nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes; max 15 mg/h
IV clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h
IV labetalol 10-20 mg IV over 1-2 minutes
want to get BP just barely below SBP <185 and DBP <110
goals is to get them to this level so that they can get tPA
If you are not eleible for tPA, what BP do you not want to treat
Do not treat unless SBP >220 or DBP >120
When do you treat even if BP is <220 or DBP <120
Additional indications for tx BP:
malignant hypertension (end organ damage)
comorbid or complicating conditions that require lowering of BP
Ex: active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre-eclampsia/eclampsia
BP should not be lowered more than 15% in the first 24 hours (to preserve cerebral perfusion)
First-line agents same as AIS eligible for rt-PA
nicardipine
clevidipine
labetolol
what organs are considered end organs?
eyes
heart
kidneys
When to treat intracranial hemorrhage and what BP goals and with what
SBP 150-220 mmHg - careful titration of therapy to allow for smooth reduction of SBP to a goal of 130-140 mmHg (Class 2a)
SBP >220 mmHg - there is currently not enough evidence to provide specific recommendations
“It is common practice to take a similar BP-lowering approach”.
First line antihypertensives same as AIS
Risk vs benefit of treatment
risk - loss of cerebral perfusion pressure leading to higher level of infarction
benefit - decreased risk of rebleed
How to treat a subarachnoid hemmorage
No optimal target has been defined - a SBP < 160 or MAP < 110 was a “reasonable” recommendation
preferred agents: labetalol, nicardipine or enalapril
Risk vs Benefit of treatment same as intracranial hemorrhage
Prevent vasospasm in SAH
Goal: prevent delayed cerebral ischemia
Nimodipine is drug of choice - given PO or via NG tube (if not cleared) and continued for 3 weeks
What is the only FDA approved therapy for stroke
Recombinant tissue-type plasminogen activator (rt-PA) - first line intervention
given over 60 minutes and blocks the blood flow
need to not have hypoglycemia
What is a complication of tPA?
Death - d/t hemmorage
3 inclusion criteria of tPA
- clinical diagnosis of ischmic stroke
- Onset of symptoms within 4.5 hours before beginning of treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal
- 18 or older
If you give tPA, what is necessary to do?
Symptoms should improve w/in 60 minutes
Infuse tPA over 60 minutes
Stop infusion and obtain CT if pt develops HA, N/V, acute HTN, or neurologic deterioration
Admit or transfer to ICU at a stroke center or specialized stroke unit
Neuro checks q15m for 3 hours, then q30m for 6 hours, then qhr x 15 hours
Keep BP < 180/105 mmHg
Avoid NG tube, indwelling catheters or intra arterial catheters if possible
Obtain CT at 24 hours post-tPA, before starting antiplatelets or anticoagulants
What to do if a patient has a bleed during tPA
cryoprecipitate¹ or tranexamic acid (TXA)²
What to do if a patient has Angioedema during tPA?
allergic reaction
IV methylprednisolone, diphenhydramine and famotidine
Consider SQ or inhaled epinephrine
prepare to intubate if edema is rapidly progressing
interventional treatment of stroke
Interventional Treatment for Ischemic Stroke - Reperfusion Therapy Option
Endovascular mechanical thrombectomy
Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6)
Indication: large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)
Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure
Specific eligibility criteria for treatment must be met if < 6 hours since onset and if treatment will occur between 6-24 hours since onset
Reference for eligibility criteria (reference only)
complications of stroke
Hematoma
Evacuation via minimally invasive surgical procedures is recommended moderate to large ICHs (Class 2a) and large intraventricular extension of ICH’s. (class 1)
Large intracranial hemorrhage
Craniotomy (allow bain to swell) vs craniectomy
Cerebral edema - worse in patients with larger infarct
peaks on day 2 or 3 - can be present for up to 10 days post stroke
monitor for increased ICP
Treatment
fluid restriction and IV mannitol - watch for hypotension leading to worse infarct
decompressive craniectomy (reduces mortality by 50%) in younger patient (< 60 y/o)
treating ICP from stroke treatment
Increased ICP - occurs most often in hemorrhagic strokes
elevate head of bed 30°
mild sedation to maintain comfort as needed
osmotic therapy (i.e. mannitol, hypertonic saline) may be considered
treating hydrocephalus for stroke complications
Hydrocephalus - increased fluid in the ventricles of the brain leading to pressure on the surrounding cerebral structures
may occur with SAH
watch for worsening HA and progressively impaired neurological testing
CT/MRI brain will show enlarged ventricles
consult neurosurgery for consideration of shunt placement
treating seizures for stroke
Seizures - occur most frequently in hemorrhagic strokes
Consider continuous electroencephalographic monitoring for at least 24 hours in hemorrhagic stroke patients
Primary prophylaxis is only recommended if impaired consciousness and evidence of seizure activity on EEG or patient hx of clinical seizures
Secondary prophylaxis for all patients and continued for at least 7 days
Active seizure controlled with IV lorazepam
Prevention with fosphenytoin
avoid phenytoin - evidence shows worsened mortality
complications that can occur after a stroke
Dysphagia and aspiration
consult speech/occupational therapy for swallowing evaluation
Venous thromboembolism
pneumatic compression stockings or heparin
UTI
Urinary incontinence
GI bleed
consider preventative PPI therapy
Depression
Nutritional deficiency, dehydration
consult nutrition
Pressure /ulcers sores
nursing orders to move patient q2h if patient unable to self adjust
Falls and bone fractures
early education, bed alarms, physical therapy consult
Pulmonary Complications
aspiration pneumonia
keep NPO until swallowing eval
mechanical ventilation
laryngeal injury, vocal cord dysfunction, swallowing impairment, tracheal stenosis, tracheoesophageal fistula, sinusitis
oxygen desaturation
continuous pulse ox, oxygen supplementation to maintain O2 sat above 94%
neurogenic pulmonary edema
unknown pathophysiology; abrupt onset, rapidly progressing pulmonary edema; supportive treatment
abnormal respiratory patterns*
Cheyne-Stoke respiration, periodic breathing, ataxic breathing, apneustic breathing, gasping, apnea
Cardiac Complications - monitor for symptoms, EKG changes and assess cardiac
management of stroke after stable
Admission
Frequent neuro checks for up to 72 hours post stroke¹
Admission consultations - with in 2 days of stroke
occupational therapy
physical therapy
speech therapy
Additional consultations on a case by case basis
Home health care coordinator
Rehabilitation coordinator
Social worker
Dietitian
Medical specialist (depending on complications)
psych, urology, GI, pulmonary, cardio, ortho
Secondary prevention of strokes
Strict BP control - once pt is neurologically stable and risk of worsening ischemia has resolved¹
2018 guidelines AIS - restart or initiate BP therapy in any patient with BP > 140/90
2022 guidelines for ICH - goal <130/80
Secondary prevention cont.
Statin therapy²
recommended in ischemic strokes
Smoking cessation
risk of stroke decreases 2-4 years after cessation
Diabetes mellitus control
Weight loss/Exercise
Low-fat/Low-salt diet
Avoid heavy alcohol intake (>4 drinks/d)
antiplatelet therapy for ischemic stroke
antiplatelet therapy for 21 days ¹ (2019 update)
(+) tPA - start ASA 24-48 hours after tPA²
(-) tPA - start ASA and Plavix within 24 hours
anticoagulant therapy ³
Indicated in patients with a potential cardiac source of embolism
MC - a. fib
other - mechanic heart valve, left ventricular thrombus, dilated cardiomyopathy, rheumatic valve disease
