EXam 4 lecture 5 Flashcards
What is a stroke?
An acute focal injury due to lack of blood/oxygen to the CNS causing neurological deficits
What ar ethe two types of strokes
Ischemic(85%) and hemorrhagic (15%)
Define ischemic stroke? Different types of ischemic stroke?
An infarction of brain tissue resulting from compromised blood flow.
Atherosclerotic ischemic stroke
Cardioembolic ischemic stroke
Define Hemorrhagic stroke
Bleeding in brain due to rupture of cerebral artery
risk factors for stroke
Non modifiable-age, race, low birth weight, sickle cell, HF, gender
Modifiable- Diabetes, HLD, HTN, CV disease (A fib, valvular disease)
Lifestyle- drug/lcohol use, obesity, ciggarette smoking
presentation of stroke
F- Face drooping
A- arm weakness
S- speech dificulty (dysphasia)
T- time to call hospital
Vision changes
Headache
What are imaging used in stroke? Vital signs?
Head CT or MRI
Blood pressure and O2 sat are important
Labs seen for stroke patients
BG
BMP
CBC
INR, aPTT
What is the use of EKG in stoke patients
We are trying to look for A- Fib.
If we have an ischemic stroke with A-Fib, we will consider that it is cardioembolic
if ischemic stroke with normal sinus rhythm, usually atherosclerotic
goals of tx of acute stroke
Limit extent of neurologic injury and long term disability
Decrease mortality
Prevent future strokes (secondary stroke prevention)
What are the three different types of strokes
cardioembolic and atherosclerotic (both ischemic)
Hemorrhagic
WHy is glycemic control important in strokes
Hypoglycemia- could mimick stroke, treat with carbohydrates
Hyperglycemia- Elevated BG (>180) has resulted in worse outcomes. Treat with SQ insulin to maintain BG below 180
What are srguments for and against reducing BP in stroke patients
Arguments for reduction-
minimize long term neurologic deficits
Decrease risk of cerebral edema and hemorrhagic transformation
Prevention of early recurrent stroke
Argument aginst reduction-
Dropping BP too quickly can limit brain perfusion, leading to worsening ischemia and neurologic function.
BP control after stroke requires balance
How often to we check BP in stroke? BP goals?
Check BP Q15 min x 2H, then q30 MIN X 6 H, THE N q 1 h for 16 H
BP goal within first 48 hours- higher than normal BP goals to allow permissive hypertension
No tPA<220/110
tPA administered- <180/105
AFter 48 hrs, goals are back to outpatient goal
acute HTN treatment for stroke pts
Always parenteral.
Labetalol, nicradipine, sodium nitroprusside
HTN management after 48 H
Start PO medications ( or restart home antihypertensives)
What are tPA
Tissue plasminogen activator (tPA). It is a thrombolytic
Alteplase and tenecteplase
They disolve clots
based on MOA of tPA, which type of stroke would you use an tPA? Does it have impact on mortality?
ischemic stroke (both of them)
No impact on mortality, but can improve neurologic function
What are the inclusion criteria for tPA
Must meet all inclusion and have none of the exclusion criteria
Inclusion
- diagnosis of ischemic stroke as confirmed by imagine (NOT for hemorrhagic)
- symotom onset < 4.5 hrs
Age > 18 yrs
What are exclusion criteria for tPA
- evidence of internal bleed
-H/o of intracranial hemorrhage
-previous stroke or head trauma in past 3 months - GI or genitourinary hemorrhage in last 21 days
- Major surgery in past 14 days
-MI in past 3 months - PLatelets < 100,000
- current anticoag use with INR > 1.7 or aPTT > 45 secs
(Can use tPA if on warfarin only with INR < 1.7 or if on heparin with aPTT< 45 seconds)
(if new oral anticoag, tPA is contraindicated)
BP> 185/110
BG < 50
What is the dose of alteplase? Max dose? How is it given?
0.9 mg/kg
max- 90 mg
10% given as bolus over 1 minute
90% infused over 60 minutes
Tenecteplase dose? max dose?
0.25 mg/kg IV
Max- 25 mg
side effects of tPA agents
bleeding
(potentially causing a hemorrhagic stroke)
Keep BP< 180/105 to reduce risk of hemorrhagic stroke
Avoid all antiplatelets and anticoags for 24 hrs
Cerebral edema
what are antiplatelet options for acute ischemic stroke management
Aspirin monotherapy
Aspirin + clopidogrel
Ticagrelor
Aspirin + Ticagrelor
MOA of aspirin? What is it indicated for? Monitring?
- irreversible inhibitor of COX enzyme, reducing the formation of thromboxane A2, thus reducing platelet aggregation.
- 1st line for acute management of ischemic stroke (160-325 mg daily)
Monitoring- Bleeding, stroke
Who gets aspirin for stroke? CI?
All ischemic stroke patients unless contraindicated.
Contraindicate din active bleeding and high bleeding risk
When to give aspirin if tPA administered? What if no tPA administered?
> 24 hrs if tPA administered, immediately if no tPA
MOA of clopidogrel? Monitoring? When is it used?
Clopidogrel is a P2Y12 inhibitor which inhibits platelet aggregation through blockade of ADP receptor
Monitoring- bleeding, stroke
Used in combo with aspirin as second line recommendation for minor stroke
MOA of ticagrelor? When is it used?
Also a P2Y12 inhibitor (like clopidogrel) Which inhibits platelets through ADP blockade.
2nd line, Only used in minor strokes
What do we do if a patient came in on a therapeutic anticoagulant for an acute ischemic stroke
Discontinue anticoagulant and transition to aspirin.
When should we restart anticoagulant for an acute ischemic patient that had an indication (cardioembolic ischemic stroke etc..)
2-14 days after stroke.
What does CHADSVASc score stand for
C- Congestive HF
H- HTN
A- age >65
D- Diabetes
S- Stroke (2 points)
V- Vascular disease
A- Age > 75
S- sex (female
BG goal for atherosclerotic and cardioembolic ischemic stroke
<180
BP goals for atherosclerotic and cardioembolic ischemic stroke
No tPA< 220/110
prior to tPA< 185/110
After tPA< 180/105
Are anticoagulants indicated in cardioembolic ischemic stroke? Atherosclerotic stroke?
Not indicated in anticoagulants
Wait 2 days for use in cardioembolic stroke
Are antiplatelets used in cardioembolic? Atherosclerotic?
Yes for both.
High dose aspirin (wait 24 hrs if tPA given)
ANtiplatelets only until covert to anticoagulants
Can we use tPA with atherosclerotic stroke? Cardioembolic stroke?
Yes for both. Same exclusion/inclusion criteria
If prior A fib, may be on oral anti coagulant so contraindicated
