Ch 1 - Stroke: Medical Treatment Flashcards
What should be done immediately to manage stroke?
ABC of critical care IVF Make NPO CT head Seizure management Check blood sugar Control ICP Control fever
Which IVF should be avoiding in stroke?
Hypotonic solutions or excessive fluid overloading can worsen brain edema
What is the treatment of hypoglycemia in stroke?
Bolus 50% IV dextrose
What is the treatment of hyperglycemia in stroke?
Insulin if blood sugar >300 mg/dL
What are the favored antihypertensives for BP control in ischemic stroke?
IV labetalol and enalapril
At what BP should antihypertensives be given in non-thrombolytic candidates?
SBP >220
DBP >120
MAP >120
At what BP should antihypertensives be given in Thrombolytic candidates (before thombolytic given)?
SBP >185
DBP >110
At what BP should antihypertensives be given in Hemorrhagic stroke?
SBP >180
DBP >105
What is the antihypertensive of choice for hemorrhage stroke?
IV labetalol (does not cause cerebral vasodilation, which could worsen increased ICP)
What are the 1st line agents for seizures (in stroke)?
IV lorazepam or diazepam
If seizures do not respond to benzodiazepines, what should be given?
Long acting anticonvulsants
– Phenytoin
– Fosphenytoin
– Phenobarbital
What is a normal ICP?
<15 mmHg
What should ICP be kept under in stroke?
<20mmHg
What can increase ICP and worsen cerebral edema?
Fever Hyperglycemia Hyponatremia Seizures Hypoxia Hypovolemia Acidosis Hypercarbia
What positioning should be avoiding in elevated ICP?
Flat/supine
Head/neck positions that compress jugular veins
What is the most rapid way of lowering ICP?
Reducing PaCO2 through hyperventilation
What can excessive hyperventilation lead to?
Hypoxia which worsens brain ischemia
What medications can improve brain edema?
Mannitol
Furosemide
Acetazolamide
What is FDA approved treatment for acute ischemic strokes?
Intravenous tissue plasminogen activator (tPA)
When can tPA be safely given and improve outcomes in stroke?
3 to 4.5 hours after stroke onset
What is the inclusion criteria for tPA?
Age >18 yo Sx onset <4.5 hrs Measurable stroke deficits Head CT neg for blood Informed consent
What are clinical exclusion criteria for tPA use?
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
What are laboratory exclusion criteria for tPA use?
PT >15 sec INR >1.7 Heparin in 24 hr with inc PTT Platelets <100,000 Blood sugar <50 or >400
What history components are exclusion criteria for tPA?
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
When can Intra-arterial fibrinolysis be beneficial?
Major ischemic strokes <6 hours post-onset caused by occlusions of the MCA who are not otherwise candidates for intravenous tPA
What is the best reason to anticoagulate a patient to decrease stroke risk?
Cardiac emboli: from nonvalvular Afib or mural thrombus from MI
When is the largest risk of intracranial hemorrhage with starting anticoagulation after stroke?
First 24-36 hours after large infarcts
What is the MOA of Warfarin (Coumadin)?
Inhibits vitamin K-dependent coagulation factors
What is the MOA of Dabigatran (Pradaxa)?
Direct thrombin inhibitor
What is the MOA of Rivaroxaban (Xarelto)?
Factor Xa inhibitor
What is the MOA of Apixaban (Eliquis)?
Factor Xa inhibitor
Which medications reduced the risk of recurrent stroke and other CV events in noncardioembolic ischemic stroke or TIA?
ASA 50-325 mg/day
aspirin/ER dipyridamole (Aggrenox®)
Clopidogrel (Plavix®)
When should ASA 325 mg be given after ischemic stroke?
First 24-48 hrs
When are Antiplatelet medications beneficial in stroke prevention?
Secondary stroke prevention of
presumed arterial origin
When is Carotid endarterectomy (CEA) beneficial?
Symptomatic lesions 70% to 99% stenosis is effective in reducing the incidence of ipsilateral hemisphere stroke
What are activity restrictions for patients after acute SAH?
Bedrest in dark, quiet room
Cardiac monitoring
Avoid all straining (give stool softeners/laxatives)
What medication is used to control cerebral edema in SAH?
Mannitol
What medications are used for headache in SAH?
Acetaminophen
Codeine
What decreases cerebral vasospasms and improves outcomes after SAH?
Nimodipine (calcium channel blocker)
What does early surgery with clipping or coiling of the aneurysm do?
Reduces risk of rebleeding but does not prevent vasospasm or cerebral ischemia
What are treatments for AVMs?
Surgical excision
Embolization
Proton beam
