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Block 8 Week 4 > Lopez-Early management of Patients w/ acute ischemic stroke > Flashcards

Lopez-Early management of Patients w/ acute ischemic stroke Flashcards

1
Q

What is the incidence of stroke?

A

greater than 800,000 strokes each year (75-80% are first strokes)

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2
Q

What is the prevalence of stroke?

Mortality?

A
  • 4.5 million survivors of stroke

- 160,000 stroke deaths each year (fourth leading cause of mortality)

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3
Q

How common is stroke?

A
  • every 40 seconds someone has a stroke

- every 3-4 minutes someone dies from a stroke

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4
Q

What is the leading cause of serious, long-term disability in adults?

A

stroke (4th leading cause in US)

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5
Q

What is the only FDA approved treatment for ischemic stroke? How many stroke patients receive IV t-PA?

A

IV t-PA

less than 5%

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6
Q

Why arent more stroke patients treated?

A
  • contraindications to t-PA
  • late presentation
  • provider reluctance
  • lack of access to acute stroke care
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7
Q

where do most stroke deaths occur?

A

south easy

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8
Q

What are the risk factors that create the ‘stroke belt’?

A

Being a poor, fat black person with obesity, HTN, smoking, DM, CAD

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9
Q

What are some warning signs of stroke?

A
  • sudden numbness or weakness of the face, arm or leg, especially on one side of the body
  • sudden trouble seeing in one or both eyes
  • sudden confusion, trouble speaking or understanding
  • sudden trouble walking, dizziness, loss of balance or coordination
  • sudden severe headache with no known cause
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10
Q

What are the three components of the Cincinnati Prehospital Stroke Scale?

A
  • Facial droop
  • Arm drift
  • Speech
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11
Q

How do you perform the Cincinnati prehospital stroke scale?

A
  • ask patient to show teeth and smile
  • ask patient to extend arms, palms down, with eyes closed
  • ask patient to say “you can’t teach an old dog new tricks”
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12
Q

What is present in 88% of all strokes and TIAs?

A

one or more of face weakness, arm weakness, and speech difficulty symptoms

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13
Q

What are some stroke mimickers?

What percent of all cases are stroke mimickers?

Can you give IV-rtPA in stroke mimickers?

A 
Seizure
Migraine
Hypoglycemia
Tumor
Multiple sclerosis
Encephalitis
Intracranial (e.g., subdural or epidural) hematoma
Intoxication or other encephalopathy

21%

yeah, it wont help but it wont hurt

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14
Q

What are the 2 types of intracranial hemorrhages and what percent of all strokes are these?

A

SAH
Intraparenchymal hemorrhages

17%

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15
Q

What are the 2 types of ischemic strokes and what percent of all strokes are these?
Which is more common, embolic or thrombotic?

A
  • thrombotic (52%)
  • embolic (32%)

83%

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16
Q

What are the types of ischemic stroke?

A
  • large artery atherosclerosis
  • cardioembolism
  • small-vessel occlusion
  • stroke of other determined etiology (i.e dissection)
  • undetermined etiology
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17
Q

How do you classify ischemic strokes?

A

TOAST

Trial of Acute Stroke Treatment

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18
Q

(blank) percent of ischemic strokes are caused by A fib

A

15%

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19
Q

What are two major ways you can get a thrombi in the left ventricle that can embolize?

A

ventricular aneurysm

acute myocardial infarction

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20
Q

(blank) can obstruct the orifices of penetrating arteries resulting in obstruction of blood flow. What does this create?

A

atheromatous plaques

Large artery thrombus

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21
Q

For cardioembolic strokes, how do you treat them?

A

with anticoagulants

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22
Q

How do you treat plaques?

A

antithrombotic

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23
Q

Smaller penetrating vessels are typically damaged how?

A

by hypertension (rather than atherosclerosis)

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24
Q

How does HTN cause damage to vessels?

A

-leads to hypertrophy of the media and deposition of fibrinoid material into the vessel wall, encroaching the lumen.

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25
Q

If you see a stroke in a lenticulate artery, what kind of stroke is it and what caused it?

A

ischemic stroke due to lipohyelinosis due to long standing HTN

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26
Q

(blank) is a non-atherosclerotic, non-inflammatory vascular disease that causes abnormal growth within the wall of an artery. It has been found in nearly every arterial bed in the body. What are the most commonly affected arteries?

A

Fibromuscular dysplasia
Renal and Carotid arteries.
(i.e overgrowth of media and intima)

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27
Q

What are the two major types of arteritis?

A

Takayasu’s

Giant-cell

28
Q

(blank) is a rare genetic lysosomal storage disease, inherited in an X-linked manner. Fabry disease can cause a wide range of systemic symptoms such as stroke

A

Fabry’s disease

29
Q

What can dissection or decreased systemic perfusion cause?

A

strokes

30
Q

What is this:
A brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than an hour and without evidence of acute infarction

A

TIA

31
Q

What is the risk of stroke after a TIA within the first 90 days?

A

10-20%

32
Q

What are some major risk factors for patients with TIA to have a subsequent stroke within the next 90 days?

A 
Age greater than 60
BP greater than 140/90
Focal weakness
Speech disturbance
-longer duration of symptoms
-Diabetes
33
Q

Which imaging is more effective in diagnosing acute ischemic stroke?

A

MRI (more effective than CT)

34
Q

Which imaging is more effective in diagnosing ICH? Which would we rather do and why?

A

both are similiarily sensitive

CT cuz it takes less time and is less expensive

35
Q

What is your goal of stroke tx?

A

improve perfusion and neuroprotection

36
Q

What is the management of acute ischemic strokes?

A
  • ABCs
  • IV fluids (Normal saline)
  • O2
  • BP management
  • Temp
  • Serum glucose
37
Q

1/3rd of stroke patients are (hyperthermic/hypothermic) and this is associated with poor neurological outcomes

A

hyperthermic

38
Q

If a patient has low glucose will insulin infusion help with stroke outcome?

A

no

39
Q

When you brain is undergoing ischemia, what do you lose?

A

cerebral autoregulation

40
Q

What will your blood pressure be like in a patient with an acute ischemic stroke prior to t-PA?

A

less than or equal to 220/120

41
Q

What will your blood pressure be like in a patient with an acute ischemic stroke with t-PA?

A

less than or equal to 180/105

42
Q

What will your blood pressure be like in a patient with a stroke who is hemorrhaging?

A

Less than or equal to 160/90

43
Q

If you cannot give your hypertensive stroke patient t-pA how do you treat them if their systolic BP is greater than 220 or their diastolic is 121-140?

A

Labetalol 10-20 mg IV. May repeat or double q 10min (max 300 mg) or
Nicardipine 5 mg/hr IV infusion; can increase 2.5 mg/hr q 5 min to max 15 mg/hr

44
Q

If you cannot give your hypertensive stroke patient t-pa how do you treat them if their DBP is greater than 140?
WHat are you aiming for?

A

nitroprusside 0.5 g/kg/min

10-15% Reduction

45
Q

if you CAN give your hypertensive patient T-PA after they have had an acute ischemic stroke, how do you treat them to lessen their BP?
(for patients with a SBP of 180-230 or DBP 121-140)

A

Labetalol 10 mg IV. May repeat or double q 10min (max 300mg) or labetalol drop 2-8 mg/min

46
Q

If you CAN give your hypertensive patient t-PA after they have had an acute ischemic stroke, how do you treat them to lessen their BP?
(for patients with a SBP greater than 230 or a DBP 121-140)

A

Labetalol 10 mg IV. May repeat or double q 10min (max 300 mg) or labetalol drip 2-8 mg/min or
Nicardipine 5 mg/hr IV infusion; can increase 2.5 mg/hr q 5 min to max 15 mg/hr
Consider nitroprusside if above ineffective

47
Q

If you CAN give your hypertensive patient t-PA after they have had an acute ischemic stroke, how do you treat them to lessen their BP?
(for patients with a DBP greater than 140)

A

nitroprusside 0.5 ug/kg/min

48
Q

You should keep BP below (blank) if not utilizing t-PA?

A

less than 220/120

49
Q

You should keep BP below (blank) if utilizing t-PA?

A

180/105

50
Q

so what are all the medications to manage stroke?

A
  • labetalol IV 10-20 mg
  • enalapril PO or IV
  • Nitroglycerine (NTG) IV drop
  • Nitroprusside
51
Q

For an ICH what do you want to keep the blood pressure at?

A

less than 180/105

52
Q

How do you give DVT prophylaxis?

A
  • subQ heparin
  • subQ enoxaparin
  • compresion boots
  • early mobilization/ambulation
53
Q

How do mnanage an acute stroke?

A

DVT prophylaxis
PT
ST
OT

54
Q

What are the neuro complications associated with stroke?

A
  • clinical worsening
  • seizures
  • increased ICP/herniation
  • depression
55
Q

When does edema peak after a stroke?

A

4 days after

56
Q

How can you resolve depression in your stroke patients?

A

SSRIs

57
Q

Overall (blank) percent of patients worsen during the first 24-48 hours after a stroke

A

25%

58
Q

What are the medical complications associated with stroke?

A
  • infections
  • DVT/PE
  • Decubitus ulcer
  • Constipation
  • Cardiac complications
59
Q

What are the 2 common infections associated with stroke?

A

aspiration pneumonia

UTI

60
Q

What are the cardiac complications associated with stroke?

A

elevation of cardiac troponin T (increases with stroke severity, mortality risk and worse outcomes)

61
Q

When do most medical complications resulting from stroke occur?

A

most commonly within the first 4 days

62
Q

What are the ischemic stroke tx strategies?

A
  • thrombolysis
  • antithrombotic therapy
  • neuroprotectio
  • hypothermia
  • neurointerventions
  • surgery
63
Q

What are the 2 types of antithrombotic therapy?

A

antiplatelets

anticoagulation

64
Q

What are the two types of heparin?

A
  • unfractionated heparin

- low molecular weight heparinoids

65
Q

When would you ue unfractionated heparin?

A

-to reduce the risk of early recurrent stroke

-

Block 8 Week 4 (8 decks)

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