Hemorrhagic Stroke Flashcards
Hemorrhagic Stroke Overview
Distinguishing symptom: severe ___
- Usually more present compared to ischemic stroke
- ___ prognosis with hemorrhagic strokes
- ncreased mortality and worse functional outcomes
- Goal is to prevent re-bleeding/worsening of bleed
- HA
- worse
Reversing Causative Medications
Warfarin: IV vitamin K
Heparin products: ___
Direct oral anticoagulants (DOACs)
- Dabigatran – ___ (Praxabind®)
- Other DOACs – recombinant coagulation factor Xa ( ____ ®)
Antiplatelets: No antidote
- protamine
- idarucizumab
- Andexxa
Surgery
Craniotomy
Endoscopic coiling or surgical clipping
Endoscopic evacuation
Antihypertensives – Acute Hemorrhagic Stroke
Theory is to prevent acute rebleeding by controlling BP, but no studies have proven this theory
Stroke guidelines (expert opinion) recommend to treat if SBP > ___ mmHg with IV antihypertensives
- Goal BP first 24 hours < ____ / ____ mmHg
- Goal BP in hospital after 24 hours is < ___ / ___ mmHg
- After 48 hours, transition to outpatient goal
- 180
- 180/110
- 160/90
Prevention of Vasospasm
After a subarachnoid hemorrhagic stroke, patients are at risk for cerebral ____ which can worsen ischemia
- Highest risk 4-21 days after subarachnoid hemorrhagic stroke
- Worsens complications after a stroke
___ (DHP calcium channel blocker) has been shown to minimize complications from cerebral vasospasm after a subarachnoid hemorrhage
- 60 mg orally Q4H for 21 days after subarachnoid hemorrhage
- vasospasm
- Nimodipine
Anticonvulsants
- There is a risk of seizure after hemorrhagic stroke
- ___ anticonvulsants are NOT recommended by stroke guidelines due to lack of benefit
- Anticonvulsants used only if patient has a documented seizure history
Prophylactic
Acute Hemorrhagic Stroke Summary
- If stroke due to a reversible cause, use ___ or ___ agents if available
- Blood pressure control vital, ___ reduces complications from cerebral vasospasm if subarachnoid hemorrhage
- Most management is supportive care
- antidote, reversal
- nimodipine
secondary stroke prevention - Antiplatelets vs. Anticoagulants
___ stroke patients will need an anticoagulant or antiplatelet to prevent future strokes
- The cause/type of ischemic stroke determines which is selected
Duration
- ___ until bleeding risk/complications
ischemic
indefinite
ASA
Place in therapy
- First-line treatment for secondary stroke prevention in ___ stroke
Dose:
- First 2-4 weeks: ___ - ___ mg PO daily
- After 2-4 weeks of high dose aspirin: < ___ mg/day indefinitely
- Similar stroke prevention with less bleeding compared to high dose
side effects/monitoring: bleeding, nausea
- atherosclerotic
- 162-325
- 162
Dipyridamole/Aspirin
Mechanism of action
- Dipyridamole inhibits adenosine phosphodiesterase thus preventing platelet aggregation
Place in therapy
- First-line treatment for secondary stroke prevention in ___ ischemic stroke
- in one study, compared to low dose aspirin, the combination of dipyridamole + aspirin decreased the risk of stroke (ESPS-2)
- not used acutely (start after using __ - __ weeks high dose aspirin after stroke)
- atherosclerotic
- 2-4
Dipyridamole/Aspirin
Dose: co-formulated capsule of dipyridamole 200 mg/aspirin 25 mg PO BID indefinitely (Aggrenox®)
Side effects/monitoring:
- ___ (can titrate up to minimize)
- Gastrointestinal bleeding
- HA
Clopidogrel
Place in therapy
- Second-line treatment for secondary stroke prevention in ___ ischemic stroke
- ___ intolerant patients
- Mostly used in ___ with aspirin
- Dose: 75 mg PO daily (Plavix®)
- side effects/monitoring: bleeding
- non-embolic
- ASA
- combo
Clopidogrel + Aspirin
Place in therapy:
- secondary stroke prevention for ___ ischemic strokes
- ___ strokes (NIHSS < 3): First-line treatment
- Moderate-severe strokes: Second line
Dose: clopidogrel 75 mg PO daily + aspirin 81 mg PO daily for 21-90 days then monotherapy
- Side effects: bleeding (increased with combo)
- atherosclerotic
- minor
Other Antiplatelets in Secondary Prevention
Neither recommended in guidelines as a treatment option for secondary stroke prevention
- ticagrelor+ ASA
- prasugrel
Antiplatelets in Secondary Prevention
1st line:
- ___
- ___ / ___
- ___ + ___ (minor)
2nd line
- clopidogrel
CI
- ___
- ASA
- ASA/dipyridamole
- clopidogrel + ASA.
- prasugrel
Anticoagulants
Recommended for ___ stroke patients caused by ___ , valvular heart disease, or severe heart failure
- initiate > __ - __ days after stroke if benefit outweighs risk
- Immediately after stroke, use ___ instead of anticoagulant as lower bleeding risk
- Once starting anticoagulant, discontinue aspirin (unless aspirin indication)
DOACs, warfarin
- if mitral valve/LV thrombuus -> ___ / ___
- cardioembolic, AFib
- 2-14
- ASA
- warfarin/rivaroxaban
Antiplatelet vs. Anticoagulant Summary
Used to prevent future occlusion of brain vasculature to minimize risk of future strokes
- ONLY use if ___ stroke, NOT ___
Antiplatelet vs. anticoagulant: when to use?
- Cardioembolic (Afib, valvular disease, LV thrombus) = ___
- Atherosclerotic/thrombotic = ___
- NOT in combination unless other indications
- ischemic, hemorrhagic
- anticoagulant
- antiplatelet
Hypertension Management
Long-term goal BP < ___ / ___ mmHg for all patients with a history of stroke per stroke guidelines (important for all
types of stroke)
Conflicting results as to best antihypertensive therapy
- One trial in stroke showed benefit of ACEis + thiazides
- With limited data, select therapies based on co-morbidities
- 130/80
Dyslipidemia
After an ___ ischemic stroke, all patients should be initiated on a high-intensity statin
- Atorvastatin 80 mg PO daily
- Rosuvastatin 20-40 mg PO daily
- LDL goal < ___ mg/dL
- Use ezetimibe (1st) and PCSK9 inhibitor (2nd) if unable to reach goal on statin monotherapy
- Do not use a statin if cardioembolic stroke or hemorrhagic stroke
(unless other indications)
- atherosclerotic
- 70
Depression After Stroke
Antidepressants
- shown to improve neurological functioning after a stroke
Recommended antidepressants
- SSRIs – sertraline, fluoxetine, escitalopram, citalopram
- AVOID: ___ and ___ (more anticholinergic)
start low, titrate up,
- duration of therapy unclear
- paroxetine, TCA
