MT2_11_Stroke Flashcards
What are the non-modifiable risk factors of stroke?
age
family hx
race (AA higher risk of death from stroke)
gender
For a thrombotic stroke what are the causes, and what to treat?
- artherosclerosis from dyslipidemia
- stenosis from dyslipidemia and hypertension
- can occur in any blood vessel of the brain
For a lunacar stroke, what are the causes , and what to treat?
- lipohyalinosis (fibroid lesion) from HTN and DM**
- microatheroma (white clots) from hyperlipidemia
- occurs in small vessels of the brain
For an artery to artery embolic stroke, what is It similar to ?
thrombotic stroke
- artherosclerosis from dyslipidemia
- stenosis from dyslipidemia and hypertension
- small pieces of thrombi break from plaque and travel downstream to create a blockage
for a cardioembolic stroke, what are the causes and what to treat?
- a clot is from the heart, stasis in the heart cause fibrin rich red clot to form, and the heart then ejects embolus to brain
- atrial fibrillation most common
and other etiologies related to systemic clot formation
When can a venous clot cause a stroke?
- when there is direct passage from the R atrium to the Left
What are the main clinical presentations of a stroke?
- sudden neurological deficit
such as numbness, weakness, confusion, difficulty speaking, aphasia (gibberish), changes in vision
How can stroke be assessed?
NIHSS scale
For diagnostic testing, what else can be looked at?
BP, HR, GLUCOSE, PT/INR, CBC, BMP, ECG
What happens in an acute ischemic stroke?
- neurologic emergency due to an occlusion of a blood vessel, decreasing oxygen supply to he brain. Target the clot
What is the primary treatment for an ischemic stroke? When is it given?
- tPA, aspiring if tPA is not given
- is usually given less than4.5 hours from onset
tPA inclusion criteria?
- diagnosis of an ischemic stroke causing a neurological deficit
- onset of symptoms less than 3 hours before beginning treatment
- greater than 18 years
- BP lowered to less than 185/110 and stable
When should tPA not be given?/ CI?
- significant head trauma in the past 3 months
- symptoms suggesting hemorrhage
- head CT with hemorrhage
- history of prev intracranial hemorrhage
- CT brain imaging with regions of irreversible injury
- intracranial or intraspinal surgery
- intra-axial neoplasm
- internal bleeding
What are other CIs to tPA?
● Acute bleeding diathesis
– Platelet count < 100k
– INR > 1.7, PT > 15 seconds
– aPTT > 40 seconds
– Treatment dose of LMWH within the previous
24 hours
– Use of direct thrombin inhibitors or direct factor
Xa inhibitors unless lab parameters normal (or
> 48 hours since last dose)
– Concomitant use of GPIIb/IIIa receptor inhibitor
What is the exclusion criteria of taking tPA within 4.5 hours from symptom onset?
over 80
severe strike
taking an oral anticoagulant
history of DM and prior ischemic stroke
Regarding BP control, what is the goal BP if giving tPA? If not?
- less than 185/110
- if not, up to 220/120
What is the dosing of tPA in an acute ischemic attack?
- 0.9 mg/kg in one hour, with 10% given as bolus over 1 minute
What are the side effects of tPA?
bleeding, anaphylaxis, orolingual angioedema, cholesterol embolization
When to monitor for tPA? How often should you check BP? BP goal?
- monitor for severe bleeding (headache, acute HTN, N/V
- every 15 minutes for 2 hours
- goal of less than 180/105
What is a hemorrhagic transformation?
- cells and tissues die, and inflammation develops around the area
- blood flow is stopped/decreased to the brain, and so when there is a sudden return of BP, the reperfusion can break through the clotted dead tissue and bleed into the head, causing a hemorrhagic transformation
- risk factors: large stroke, high BP, use of fibrolynics, anitplatelets, antifibrinolytics
For a subacute stroke (inpatient) what are the steps of treatment?
- Antiplatelet (aspirin within 24-48hrs if TPA given with 24 hours after, clopidogrel, aspirin and clopidogrel for 21 days)
- BP Control (if getting tPA, less than 185/110, maintain less than 180/105) if not getting tPA decrease bp by 15%, can restart HTN therapy if BP is greater than 140/90
- BG Control (goal of 140-180)
- Statin continue, due to anti-inflammatory and neuroprotective properties)
- Supportive Care (oxygen, body temp, fluid restriction..ensure adequate perfusion, correct hypovolemia w NS 0.9%
- Additional Diagnostic Tests (Protein C, S, anithrombin, lupus, anticoagulant, ECG, blood vessel imaging)
- Potential Complications (infections, DVT/PE, ulcers, dysphagia, seizures)
Transient ischemic attack
- aka a mini stroke, temporarily blocks blood flow
For a carotid artery stenosis?How to treat
- if there is a complete occlusion, no treatment, allow collateral artery to provide flow and ensure potency
- if partial occlusion, surgically remove (carotid endarterectomy) or angioplasty or prescribe meds
For a cranial/cervical artery dissection, what happens?
- a tear in the vessel wall, results in clot formation due to trauma or falls, resulting in a higher risk of clot mobilization
- treat with anti platelet or anticoagulation (warfarin, heparin, aspirin, clopidogrel)
What are the steps to secondary prevention for noncardioembolic stroke?
- anti-platelet (aspirin, aspirin + dipyridamole (Caution in elderly, recent MI or unstable angina) s/e of headache/bleeding, and dose aspirin 25mg+dipyridamole 200mg POVID, clopidogrel 75mg PO QD, cilostazol: CI in CHF patients, 100mg BID)
- antihypertensive
- antihyperlipidemic
- lifestyle modifications (blood glucose, smoking, alcohol consumption, obesity and PE)
For fib anticoagulation, how does anticoagulation therapy work?
- use oral anticoags: warfarin (goal INR 2-3), dabigatrin (DTI), rivaroxaban apixaban, endoxaban (factor 10)
- antiplatelts only if patient CANT be treated with anticoags
What are the factors in choosing an anticoagulant in patients/
- compliance, diet, CKD, reversibility
For hemorrhagic stroke, what is an intracerebral hemorrhage? subarachnoid hemorrhage?
- bleeding directly into brain tissue
- bleeding beneath arachnoid mater
What are the risk factors for intracerebral hemorrhage?
- HTN, age, smoking, alcohol, low LDL, fam hx
What are the symptoms of intracerebral hemorrhage?
- headache
- decreased level of consciousness
- vomiting
- seizure
How to manage intracerebral hemorrhages?
- BP control goal of 40
- maintain cerebral perfusion pressure 70-80 (CPP = MAP-ICP)
- titratable meds, nicardipine, nitroprusside
For secondary prevention of intracerebral hemorrhage, what to do?
- maintain HTN BP less than 130/80
- lifestyle modification (alcohol, tobacco, drug use)
- timing of restarting anticoagulation or anti platelet agents
What causes a subarachnoid hemorrhage?
- primary aneurysmal rupture
What are the risk factors for a subarachnoid hemorrhage?
● Hypertension ● Smoking ● Family history ● Alcohol consumption ● Oral contraceptive use ● Pregnancy ● Childbirth ● Illicit drug use (cocaine, methamphetamines)
Symptoms of a subarachnoid hemorrhage?
- worst headache of one’s life
- nausea/vomiting
- neck pain
- altered LOC
- seizures
What is the goal of therapy fora. subarachnoid hemorrhage?
- prevent rebreeding , prevent vasospasm (narrowing of the vessel)
How to manage rebleeding? vasospasm?
- for rebreeding, surgical intervention, and aminocaproic acid
- vasospasm: nimodipine 60mg PO q4H for 21 days
augment cerebral circulation (hypervolemia, hemodilution, HTN therapy)
What are other complications of a stroke?
- infections
- DVT/PE
Seizure - dysphagia
