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701 > Exam 2: Stroke > Flashcards

Exam 2: Stroke Flashcards

1
Q

Transient Ischemic Attack definition

A

Cerebral ischemic event lasting less than 24 hours (typically only minutes) without apparent permanent neurological deficit
Clot self destruct in time

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2
Q

Completed Stroke definition

A

Cerebral ischemic acute event with deficit that persists
Lasting symptoms from tissue hypoxia despite restoration of perfusion
Clot does not self destruct in time

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3
Q

What other etiologies can present as a stroke?

A

Some of the most common stroke mimics are seizures, migraine, fainting, serious infections and functional neurological disorder (FND).

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4
Q

Use of thrombolytic therapy (tPA) in stroke is for

A

Acute management of stroke tPA

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5
Q

Inclusion therapy for thrombolytics

A

Diagnosis of ischemic stroke causing measurable deficit
Onset of symptoms less than 4.5 hours prior to treatment
(3 hrs if patient ≥80 y/o!!)
age ≥18 y/0 (no peds!)

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6
Q

Exclusion criteria for thrombolytics

A
  • ischemic stroke/significant head trauma within 3 months
  • ANY hx intracranial hemorrhage
  • intracranial neoplasm, AVM, aneurysm
  • Active internal bleeding
  • ELEVATED BP >185/110
  • INR >1.7
  • Use of direct thrombin inhibitors/direct factor Xa inhibitors
  • use of heparin within 48 hrs + elevated aPPT
  • BG < 50 mg/dL
  • Plt < 100,000
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7
Q

Relative exclusion criteria for tPA

A
  • minor sx are rapidly improving
  • seizure at onset – postictal neurologic deficit
  • Major surgery/trauma in past 14 days
  • Recent GI bleed (~21 days)
  • Recent acute MI (~3 months)
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8
Q

additional tPA exclusion for time window: 3 hr – 4.5 hrs

A

if age >80
severe stroke (NIH score >25)
Hx of stroke AND diabetes

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9
Q

Metabolic rate of the brain

A

“the brain is a tyrant”
Tremendous O2 and energy demands, does little work

2% BW but receives 17% of CO and consumes 20% of O2

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10
Q

Grey Matter of brain

A

Lots of redundancies in cortical tissue supply at microvascular level
Capillary arborization

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11
Q

White matter of the brain

A

Occlusion = supply is cut off
Single penetration micro vessels

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12
Q

Types of strokes

A

71% Ischemic
26% Hemorrhagic
3% other

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13
Q

Ischemic stroke types

A

32% unknown
19% Lacunar
14% embolic
6% Thromboembolic

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14
Q

Hemorrhagic stroke types

A

13% SAH
13% ICH

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15
Q

Cumulative risk of stroke after TIA or complete stroke

A

A person who had a TIA is just as at risk of developing another stroke as someone who had a complete stroke

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16
Q

Treatable risk factors for stroke

A
  1. HTN
  2. HLD
  3. heart disease
  4. DM
  5. Cigarette smoking
  6. Excessive EtOH intake
  7. Physical inactivity
  8. Obesity
  9. Carotid bruit
  10. POST MENOPAUSAL HORMONE THERAPY (estrogen)
  11. Afib, CAD
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17
Q

Untreatable risk factors for stroke

A
  1. Age (>55)
  2. Sex (male)
  3. Race (hispanic)
  4. Prior stroke (personal hx)
  5. Heredity (family hx)
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18
Q

T/F: the number of strokes have not gone down, but the severity of strokes have

A

true

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19
Q

T/F most stroke risk factors are treatable by Rx interventions

A

true

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20
Q

Clinical presentation of carotid stroke/tia

A
  1. Unilateral weakness
  2. Unilateral sensory
  3. Aphasia (speaking/understanding)
  4. Monocular vision loss
  5. Transient global amnesia
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21
Q

Clinical presentation of vertebrobasilar stroke/tia

A
  1. BILATERAL weakness
  2. BILATERAL sensory
  3. BILATERAL vision complaints
  4. Diplopia
  5. Vertigo
  6. Ataxia w/o weakness
  7. Dysphagia
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22
Q

Antiplatelet therapy (secondary prevention)

A

Small vessel lacunar
Large vessel embolic
Large vessel thrombotic

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23
Q

Warfarin (secondary prevention)

A

Cardioembolic event

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24
Q

Drugs that block ADP

A

Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brilinta)

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25
Q

Drug that inhibits COX and Thromboxane

A

Aspirin

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26
Q

Drug that inhibits plasma adenosine and platelet phosphodiesterase

A

Dipyridamole

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27
Q

How do you individualize antiplatelet therapy?

A

All are equally good statistically
Pick the one that suits the patient’s needs
- best ADR profile
- produces inhibition of aggregation in the patient
- use in lowest effective dose to reduce bleed risk

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28
Q

T/F GI bleeds are the result of SYSTEMIC inhibition of PGE, not a local GI irritation

A

True

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29
Q

Will enteric forms of aspirin decrease GI bleed risk?

A

NO

30
Q

Asprin dosing

A

Start at 81mg (take a week to work)
If pt needs rapid antiplt therapy, give 325mg (within 4 hours)

31
Q

Patients that warrant DAPT

A
  • CA stents + new cerebral ischemia
  • cerebral ischemia within 90 days of
  • Afib but can’t use anticoagulant
  • Cerebral vessel dissection
32
Q

T/F ASA resistant patients are at increased risk for stroke

A

true

33
Q

Middle cerebral artery infarct

A

disrupt 2/3 of flow from middle CA
CA infarction = catastrophic stroke

34
Q

Lacunar infarct

A

multiple lacunar infarcts, usually periventricular
always small, in white matter of brain

35
Q

Microvascular Ischemic White Matter Lesions

A

Nonspecific
Most subtle~
Often asymptomatic
Hard to detect
May become symptomatic if lesions become confluent

36
Q

Less than optimal: Migraine hx

A

Aggrenox
dipyridamole/ASA
(worsens HA)

37
Q

Less than optimal: rapid antiplt effect

A

If need fast, avoid low dose ASA or Clopidogrel
» do loading dose or lead in therapy
- ASA 325 response in 4 hours, follow up with 81
- Clopidogrel 75 takes 1 week

38
Q

Less than optimal: Spastic colon or IBS or gastric ulcer

A

Avoid ASA
especially higher dose 325mg enteric form

39
Q

Less than optimal: CCB

A

Avoid clopidogrel or prasugrel with amlodipine/nicardipine
2C19/3A4

40
Q

DDI considerations for stroke ppx meds

A

if patient also needs
- chronic NSAID
- chronic PPI
- CCB

41
Q

DAPT therapy considerations

A
  • failure of monotherapy
  • first 3-6 mon post stroke w/ high RF
  • Afib w/ anticoags contraindicated (can only use antiplt)
42
Q

ASA resistance approach

A
  1. Check compliance
  2. Remove drugs that compromise ASA effects
  3. Change
  4. Change EC to chewable or seltzer
  5. Change ASA dose
43
Q

Drugs that compromise ASA effects

A

NSAIDs (other than celebrex)
some herbal supplements

44
Q

What to do if patient has GERD and req. antiplt (plavix/prasugrel)?

A

Take off omeprazole.
Start famotidine or pantoprazole.

45
Q

Plavix (clopidogrel) resistance approach

A
  1. minimize drugs that inhibit 3A4/2C19
  2. Sub with drugs with less P450 effect
  3. add meds that induce CYP activity
46
Q

Common meds that influence CYP 3A4 or 2C19

A
  1. statins (rosuvastatin least likely to interfere)
  2. CCBs only (not BB/ACEi)
  3. Z drugs: ambien, lunesta, (sonata least likely)
  4. Glyburide (not glipizide or metformin)
  5. Enablex, Ditropan (not detrol/sanctura)
  6. PPI (except pantoprazole?)
47
Q

What do you do if patient is truly resistant to both ASA and clopidogrel (plavix)

A

use Brilinta (ticagrelor)
90mg BID

48
Q

T/F all cause mortality in the HEALTHY elderly population is higher for those taking daily ASA than those who received placebo

A

true

49
Q

Acute stroke management

A
  1. emergent transport
  2. stabilization
  3. detailed hx from pt/witness
  4. PE
  5. imaging
  6. labs
50
Q

NIH stroke scale purpose

A

gives idea of severity and location of stroke
>20 = severe deficit, no tPA
4-20 = mild-mod ideal for tPA
<4 = good prognosis, no tPA

51
Q

NIH stroke scale measures s/s

A

visual changes
facial droop
motor fnc of arms/legs
limb ataxia
sensory changes
language
dysarthria

52
Q

Acute stroke management goal

A

reperfusion asap
- reduce ongoing CNS injury

53
Q

Acute stroke treatment options

A
  1. IV-tPA (within 2 hrs of stroke)
  2. Endovascular intervention
    Both?
54
Q

stroke time window <2 hrs

A

reversible deficits

55
Q

stroke time window 2-6 hrs

A

some but incomplete recovery

56
Q

stroke time window > 6 hours

A

little recovery

57
Q

5 signs of stroke

A

balance is off
speech slurred/face droopy
vision all or partial loss
headache severe

58
Q

Collecting stroke history

A

when were they last seen normal
has this happened before
do they have other conditions that can mimic stroke?
what medications do they take?
recent medical/surgical history

59
Q

To give tPA, onset of sx must be <4.5 hrs. What if the patient is 80 years old?

A

must be within 3 hours!! they are greater risk

60
Q

RIsk factors for bleeding (upon acute stroke tx w. thrombolytics)

A

if baseline NIH >20
Protocol deviations
- anticoag or antplt given within 24 hrs
- tPA given beyond 4 hrs
- elevated blood pressure (HTN)
Baseline serum glucose > 200 mg/dL
Advanced age
edema or mass effect on CT scan

61
Q

s/s of cns bleeding

A

acute neurological change/deterioration
headache
n/v
acute HTN
change in alertness (lethargy)

62
Q

Most important ADR of tPA is

A

intercerebral brain hemmorhage
~7% risk of symptomatic bleed in clinical trials

63
Q

What do you use if patient is ineligible for IV tPA?

A

intra-arterial thrombolysis (IA)

64
Q

How does dosing of IA tPA differ from IV tPA?

A

IA tPA is a lower dose ~20mg

65
Q

When can we use IA tPA

A

when patient can’t use IV
symptom onset <6 hrs
MCA occlusions

66
Q

When giving IV tPA, what are the blood pressure goals?

A

bp MUST be
< 180 systolic
< 110 diastolic

67
Q

Agents of choice for BP lowering during acute stroke tx

A

labetalol 10-20 mg IV
- may repeat or double dose every 10 minutes

Nicardipine 5mg/hr IV titrated to effect

68
Q

If patient is not a tPA candidate, is HTN permissive?

A

Want to value perfusion&raquo_space; BP control
ALLOW BP up to 220 mmHg systolic

69
Q

tPA

A

Alteplase
fibrin specific “clot busting”

70
Q

Dosing tPA

A

0.9 mg/kg actual body weight
(MAX = 90mg)
- 10% given as initial bolus over 1 minute
Must keep BP<180 mmHg systolic for 24 hrs

701 (16 decks)

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