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Cuccurullo Book > Ch 1 - Stroke: Medical Treatment > Flashcards

Ch 1 - Stroke: Medical Treatment Flashcards

1
Q

What should be done immediately to manage stroke?

A 
ABC of critical care
IVF
Make NPO
CT head
Seizure management
Check blood sugar
Control ICP
Control fever
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2
Q

Which IVF should be avoiding in stroke?

A

Hypotonic solutions or excessive fluid overloading can worsen brain edema

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3
Q

What is the treatment of hypoglycemia in stroke?

A

Bolus 50% IV dextrose

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4
Q

What is the treatment of hyperglycemia in stroke?

A

Insulin if blood sugar >300 mg/dL

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5
Q

What are the favored antihypertensives for BP control in ischemic stroke?

A

IV labetalol and enalapril

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6
Q

At what BP should antihypertensives be given in non-thrombolytic candidates?

A

SBP >220
DBP >120
MAP >120

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7
Q

At what BP should antihypertensives be given in Thrombolytic candidates (before thombolytic given)?

A

SBP >185

DBP >110

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8
Q

At what BP should antihypertensives be given in Hemorrhagic stroke?

A

SBP >180

DBP >105

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9
Q

What is the antihypertensive of choice for hemorrhage stroke?

A

IV labetalol (does not cause cerebral vasodilation, which could worsen increased ICP)

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10
Q

What are the 1st line agents for seizures (in stroke)?

A

IV lorazepam or diazepam

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11
Q

If seizures do not respond to benzodiazepines, what should be given?

A

Long acting anticonvulsants
– Phenytoin
– Fosphenytoin
– Phenobarbital

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12
Q

What is a normal ICP?

A

<15 mmHg

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13
Q

What should ICP be kept under in stroke?

A

<20mmHg

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14
Q

What can increase ICP and worsen cerebral edema?

A 
Fever
Hyperglycemia
Hyponatremia
Seizures
Hypoxia
Hypovolemia
Acidosis
Hypercarbia
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15
Q

What positioning should be avoiding in elevated ICP?

A

Flat/supine

Head/neck positions that compress jugular veins

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16
Q

What is the most rapid way of lowering ICP?

A

Reducing PaCO2 through hyperventilation

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17
Q

What can excessive hyperventilation lead to?

A

Hypoxia which worsens brain ischemia

18
Q

What medications can improve brain edema?

A

Mannitol
Furosemide
Acetazolamide

19
Q

What is FDA approved treatment for acute ischemic strokes?

A

Intravenous tissue plasminogen activator (tPA)

20
Q

When can tPA be safely given and improve outcomes in stroke?

A

3 to 4.5 hours after stroke onset

21
Q

What is the inclusion criteria for tPA?

A 
Age >18 yo
Sx onset <4.5 hrs
Measurable stroke deficits
Head CT neg for blood
Informed consent
22
Q

What are clinical exclusion criteria for tPA use?

A 
Minor stroke/TIA
CT head + blood
BP >185/100 despite tx
Acute MI
Seizure at onset of stroke
On anticoagulants
>80 yo
NIHSS score >25
Ischemic injury > 1/3 of MCA territory
23
Q

What are laboratory exclusion criteria for tPA use?

A 
PT >15 sec
INR >1.7
Heparin in 24 hr with inc PTT
Platelets <100,000
Blood sugar <50 or >400
24
Q

What history components are exclusion criteria for tPA?

A 
Stroke or head injury in 3 mo
ICH, AVM or aneurysm
GI or GU bleeding in 21 days
Pregnancy last 30 days
Major surgery in 14 days
History of stroke and DM
25
Q

When can Intra-arterial fibrinolysis be beneficial?

A

Major ischemic strokes <6 hours post-onset caused by occlusions of the MCA who are not otherwise candidates for intravenous tPA

26
Q

What is the best reason to anticoagulate a patient to decrease stroke risk?

A

Cardiac emboli: from nonvalvular Afib or mural thrombus from MI

27
Q

When is the largest risk of intracranial hemorrhage with starting anticoagulation after stroke?

A

First 24-36 hours after large infarcts

28
Q

What is the MOA of Warfarin (Coumadin)?

A

Inhibits vitamin K-dependent coagulation factors

29
Q

What is the MOA of Dabigatran (Pradaxa)?

A

Direct thrombin inhibitor

30
Q

What is the MOA of Rivaroxaban (Xarelto)?

A

Factor Xa inhibitor

31
Q

What is the MOA of Apixaban (Eliquis)?

A

Factor Xa inhibitor

32
Q

Which medications reduced the risk of recurrent stroke and other CV events in noncardioembolic ischemic stroke or TIA?

A

ASA 50-325 mg/day
aspirin/ER dipyridamole (Aggrenox®)
Clopidogrel (Plavix®)

33
Q

When should ASA 325 mg be given after ischemic stroke?

A

First 24-48 hrs

34
Q

When are Antiplatelet medications beneficial in stroke prevention?

A

Secondary stroke prevention of

presumed arterial origin

35
Q

When is Carotid endarterectomy (CEA) beneficial?

A

Symptomatic lesions 70% to 99% stenosis is effective in reducing the incidence of ipsilateral hemisphere stroke

36
Q

What are activity restrictions for patients after acute SAH?

A

Bedrest in dark, quiet room
Cardiac monitoring
Avoid all straining (give stool softeners/laxatives)

37
Q

What medication is used to control cerebral edema in SAH?

A

Mannitol

38
Q

What medications are used for headache in SAH?

A

Acetaminophen

Codeine

39
Q

What decreases cerebral vasospasms and improves outcomes after SAH?

A

Nimodipine (calcium channel blocker)

40
Q

What does early surgery with clipping or coiling of the aneurysm do?

A

Reduces risk of rebleeding but does not prevent vasospasm or cerebral ischemia

41
Q

What are treatments for AVMs?

A

Surgical excision
Embolization
Proton beam

Cuccurullo Book (91 decks)

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