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864 > Hemorrhagic Stroke > Flashcards

Hemorrhagic Stroke Flashcards

1
Q

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

A
  • HA
  • worse
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2
Q

Reversing Causative Medications

Warfarin: IV vitamin K

Heparin products: ___

Direct oral anticoagulants (DOACs)
- Dabigatran – ___ (Praxabind®)
- Other DOACs – recombinant coagulation factor Xa ( ____ ®)

Antiplatelets: No antidote

A
  • protamine
  • idarucizumab
  • Andexxa
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3
Q

Surgery

A

Craniotomy
Endoscopic coiling or surgical clipping
Endoscopic evacuation

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4
Q

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

A
  • 180
  • 180/110
  • 160/90
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5
Q

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

A
  • vasospasm
  • Nimodipine
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6
Q

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
A

Prophylactic

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7
Q

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
A
  • antidote, reversal
  • nimodipine
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8
Q

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

A

ischemic
indefinite

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9
Q

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

A
  • atherosclerotic
  • 162-325
  • 162
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10
Q

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)

A
  • atherosclerotic
  • 2-4
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11
Q

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

A
  • HA
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12
Q

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

A
  • non-embolic
  • ASA
  • combo
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13
Q

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)

A
  • atherosclerotic
  • minor
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14
Q

Other Antiplatelets in Secondary Prevention

Neither recommended in guidelines as a treatment option for secondary stroke prevention

A
  • ticagrelor+ ASA
  • prasugrel
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15
Q

Antiplatelets in Secondary Prevention

1st line:
- ___
- ___ / ___
- ___ + ___ (minor)

2nd line
- clopidogrel

CI
- ___

A
  • ASA
  • ASA/dipyridamole
  • clopidogrel + ASA.
  • prasugrel
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16
Q

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 -> ___ / ___

A
  • cardioembolic, AFib
  • 2-14
  • ASA
  • warfarin/rivaroxaban
17
Q

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

A
  • ischemic, hemorrhagic
  • anticoagulant
  • antiplatelet
18
Q

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

A
  • 130/80
19
Q

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)

A
  • atherosclerotic
  • 70
20
Q

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

A
  • paroxetine, TCA

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