E4 Stroke (pause) Flashcards by Cole O'Connor

2 classes of stroke we talk about

ischemic and hemorrhagic

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where do atheroscletoric and cardioembolic strokes fall?

under ischemic

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which type of stroke has headache as a clinical presentation more often?

hemorrhagic (cause its the brain duh)

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what scale is used for sx evaluation

National Institutes of Health Stroke Scale (NIHSS)
has a score 0-42

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if ischemic stroke with _______ or _______ usually cardioembolic

Afib, valvular abnormalities

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if ischemic stroke with _______ usually atherosclerotic

normal sinus rhythm

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what two tests are used to assess stroke

ECG
echocardiogram

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what 4 labs are used in assessment of stroke

BG
BMP
CBC
INR/aPTT

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what two vital signs are used in assessment of stroke

BP
o2 sat

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what two imaging things are used for assessment of stroke

Head CT
MRI

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can cause neurological changes mimicking a stroke
A. Hypoglycemia
B. Hyperglycemia

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treat with carbs
A. Hypoglycemia
B. Hyperglycemia

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if hyperglycemic when presenting treat with insulin in BG > ___

180

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when to use insulin drip in pts presenting with hyperglycemia and stroke

only if patient is in acidosis *

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acute BP goals:
check BP how often?

q15 min x 2h, then q30 min x 6h, then q1 h for 16 hours
damn

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BP goals within first 48 hours:*****
no tPA:
tPA admin:

<220/110
<180/105

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do i need to know the details from slide 31? ( i think its 31 but its the flow chart)

spencer pls

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3 drugs for acute htn tx options in acute ischemic stroke

labetalol
nicardipine
sodium nitroprusside
all are quick onset
dont need doses

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htn management after 48 hours:
if BP elevated after 48 hrs, do what

start po meds if able to take OR resume home antihypertensives

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2 tPA drugs

alteplase
tenecteplase

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what do tPAs activate and what does that do

plasminogen -> breaks clots

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T or F:
thrombolytics (tPAs) improve mortality and neurologic function

false, no impact on mortality

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what are the 3 inclusion criteria for tPA eligibility

diagnosis of ischemic stroke
sx onset of <4.5 hours*
age >18 yo

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Based on the mechanism of action, which type of stroke would you use a thrombolytic? Select all that apply.
A. Hemorrhagic
B. Ischemic – atherosclerotic
C. Ischemic - cardioembolic

B and C

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what BG level is considered hypoglycemic

<50

for tPA eligibility you need to meet ALL inclusion and NO exclusion criteria

yes

what BP value is in exclusion criteria for tPA eligibility ***

BP >185/110 at time of admin

what are some of the tPA exclusion criteria things that might pop up based on his practice questions

active internal bleed MI in last 3 months platelets <100k any current anticoag use

alteplase dose and max

0.9mg/kg max 90mg

tenecteplase dose and max

0.25mg/kg max 25 mg

alteplase dosing regimen (ignore actual dose for this)

10% given as bolus 90% given over 1 hour

tenecteplase dosing regimen (ignore actual dose for this)

all IV bolus

2 SEs of tPA agents

bleeding duh cerebral edema

after giving tPA keep BP at what value to reduce risk of bleeding/hemorrhagic stroke***

<180/105

what should you avoid for 24 hours after tPA admin *

ALL antiplatelets and anticoags

antiplatelets decrease activation of?

P2Y12

4 antiplatelet options for acute ischemic stroke management

aspirin mono aspirin+clopid ticagrelor aspirin +ticag

T or F: aspirins inhibition of COX is reversible

false, irreversible

inhibiting COX reduces formation of ?

thromboxane A2 -> reduces platelet agg

aspirin utility: - __ line for acute mgmt of ischemic stroke - studies show a decrease in early recurrent ischemic stroke with ?

1st high dose aspirin for 2-4 weeks*

2 monitoring for aspiri

bleeding stroke

who gets aspirin for a stroke

ALL ischemic stroke pts unless CI'd

what are 2 CI's of aspirin use

active bleeding or high bleeding risk

when to give aspirin if tPA administered and if not administered

>24 hours with tPA immediately if not*

use aspirin+clopid ONLY in ?

minor strokes (NIHHS <4)

how long to use aspirin + clopid combo

3 weeks or 90 days but 90 days increases bleed risk

ticagrelor only used in?

minor strokes (NIHHS <5)

T or F: aspirin + ticagrelor is better than ticagrelor alone

true

if pt has a true aspirin allergy what do you use?

ticagrelor (yes even over clopid)

what do we do if a pt came in on anticoags already when they came for ischemic stroke

d/c and transition to aspirin

if cardioembolic ischemic stroke or other indication for anticoag, start > __-__ days after stroke *(quiz question)

2-14 days but his quiz said after 7 so just use that range

distinguishing sx of hemorrhagic stroke

severe headache

T or F: worse prognosis with hemorrhagic stroke

true duh

warfarin reversal agent

IV vitamin K

heparin products reversal agent

protamine

dabigatran (DOAC) reversal agent

idarucizumab

other DOAC reversal agent

Andexxa

antiplatelet reversal agent

none

management is mostly surgical A. cardioembolic B. Atherosclerotic C. Hemorrhagic

stroke guidelines recommend to treat with IV antihtn if SBP > ___

180

goa BP in first 24 hours for hemorrhagic stroke

<180/100*

goal BP in hospital AFTER 24 hours for hemorrhagic stroke

<160/90

outpatient BP goal for hemorrhagic stroke

<140/90

what type of stroke gives pts a risk of cerebral vasospasm

subarachnoid hemorrhagic stroke

what to give to minimize complications from cerebral vasospasm

nimodipine (DHP CCB)

T or F: prophylactic anticonvulsants are recommended by stroke guidelines after a hemorrhagic stroke

false, lack of benefit

anticonvulsants only used if pt has?

documented seizure history

atherosclerotic stroke pts receive what to prevent future strokes

antiplatelets

cardioembolic stroke pts receive what to prevent future strokes

anticoag

1st line for secondary stroke prevention in atherosclerotic stroke

aspirin, high dose 2-4 weeks then 81 indefinitely

my bad theres another 1st line for secondary stroke prevention in atherosclerotic stroke what is it

dipyridamole + aspirin

dipyridamole inhibits ?

adenosine phosphodiesterase

1 niche side effect for dipyridamole aspirin combo

headache

2nd line for secondary stroke prevention in non-embolic ischemic stroke (mod/sev)

clopidogrel + aspirin

1st line for secondary stroke prevention in non-embolic ischemic stroke (minor)

clopid+aspirin

drug that is CI'd in secondary prevention

prasugrel

when to give warfarin/rivaroxaban in cardioembolic stroke

if mechanical mitral valve/LV thrombus

high dose aspirin for >2 days A. Atherosclreotic B. Cardioembolic

B, A is 2-4 weeks

long term BP goal for all pts w/ hx of stroke

<130/80

first line antihypertensives: black people

CCB, thiazide

first line antihypertensives: CKD

ACE/ARb

first line antihypertensives: CAD

BB + ACE (or ARB)

first line antihypertensives: diabetes

ACE or ARB

first line antihypertensives: HF

ARNI, ACE, ARB + BB + spiro (duh)

first line antihypertensives: Afib

BB or non-DHP CCB

after an atherosclerotic stroke, all pts should be initiated on ?

high intensity statin

LDL goal

<70

do not use a statin if what or what?

cardioembolic or hemorrhagic stroke

? have been shown to improve neurological functioning after a stroke

SSRis, just avoid paroxetine