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Isbp > Stroke > Flashcards

Stroke Flashcards

1
Q

What is the gold standard for diagnosing stroke?

A

Non-contrast head ct

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2
Q

Stroke can lead to what two diseases?

A

Depression and Dementia

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3
Q

What is the cause of hemorrhagic stroke?

A

Bleeding

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4
Q

What is the cause of ischemic stroke?

A

Clotting

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5
Q

Patho of hemorrhagic stroke

A

Hematoma is formed in the parenchyma without blood extension into the ventricles. Subsequent bleeding around the clot causes swelling

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6
Q

In ICHS- swelling around the hematoma causes

A

Increase risk of mortality

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7
Q

What can the non contrast head Ct confirm?

A

Size, edema, raised intracranial pressures and what kind of stroke it is

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8
Q

Why don’t we use MRI

A

Takes more time and less readily available

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9
Q

What are some parameters to diagnose hemorrhagic stroke?

A

Unresponsiveness
Elevated BP
Neck pain
Vomiting
Seizures
*these do not differentiate between strokes but can give clues if it is hemorrhagic

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10
Q

What is the first thing that should be done to treat a patient with stroke?

A

Stabilize- ABCs

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11
Q

What is ABCs?

A

Airway
Breathing
Circulations

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12
Q

What lab test should be ordered with the head ct either during or before?

A

Glucose finger stick

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13
Q

What is one main mimic of stroke to look for?

A

Hyperglycemia - so fix and will go away

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14
Q

If patient is on an anticoagulant we need to reverse it, why?

A

Coagulation is a factor deficiency and needs to be corrected

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15
Q

Reversal for warfarin(vit k antagonist)

A

Give vit k with PCC
Or FFP

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16
Q

Why is PCC chosen over FFP?

A

Faster reversal and religious reasons may not want FFP

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17
Q

Davigatran reversal:

A

Idaruciumab

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18
Q

Xa inhibitors:

A

Andexant alfa or PCC if unavailable

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19
Q

Heparin:

A

Protamine sulfate

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20
Q

Should we do platelet infusions?

A

No, platelet transfusion increases the risk of death or dependence if patient is on anti platelet therapy.

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21
Q

What is the one exception that we can give platelets?

A

If platelet count < 100,000

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22
Q

When should we manage BP?

A

If greater than 185/110
If less than—-don’t treat

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23
Q

What agents do we use for BP control?

A

Nicardipine
Labetolol
Clevidipine

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24
Q

What is the difference between nicardipine and labetolol?

A

Nicardipine infusion is nice smooth drop of Bp as to labetolol is more choppy (iv push)

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25
Q

If bleed is in the cerebellum what should we do?

A

Surgical emergency

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26
Q

If ich ruptures into ventricles and intravascular hematoma, it can form a thrombis and obstruct outflow causing:
What should we do?

A

Hydrocephalus
External ventricular drain

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27
Q

What if there are seizures?

A

We treat them but never use as prophylaxis

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28
Q

What other treatments should we do?

A

Pain and fever with acetaminophen
Maintain euglycemia
DVT prophylaxis- give pneumatic compression stockings

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29
Q

For DVT when can we give an anticoagulants?

A

Heparin or LMWH 1-4 days after

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30
Q

If intracranial HTN happens give?

A

Osmotic therapies - hypertonic saline or mannitol

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31
Q

What is an hemorrhagic transformation?

A

Bleeding in the area of the ischemic brain after stroke
Caused by peripheral blood in bbb disruption usually after tpa given
Increased m&m
Essentially ischemic to hemorrhagic

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32
Q

What are the risk factors for hemorrhagic transformation?

A

Reperfusion therapy, stroke severity, HTN, age, hyperglycemia, inflammation and immune system

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33
Q

What is the treatment for hemorrhagic transformation?

A

Reversal agents for tpa
1. Cryoprecipitate
2. FFP, PCC, vit k
3. Antifibrinolytics - amino caprock and tranexamic acid

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34
Q

What is the goal of cryoprecipitate?

A

Increase fibrinogen by 60mg/dl
Goal: >/= 150 mg/dL

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35
Q

When should we give FFP, PCC, vit k?

A

For patients who were on warfarin and inr < 1.7 prior to tpa

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36
Q

When should we give the antifibrinolytics?

A

In patients who don’t want blood products

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37
Q

The majority of strokes is ?

A

Ischemic

38
Q

What is a transient ischemic attack?

A

Stroke that is not permanent
Caused by cerebral edema
Temporary blockage of artery
Patients are at a higher risk for subsequent strokes

39
Q

What is the ABCD2 score?

A

To asses the risk of future strokes

40
Q

How do you score patients in the ABCD2?

A

0-3: low risk
4-5: moderate risk
6-7: high risk
Patients with high risk are admitted to hospital for imaging

41
Q

Tia is a ——- for stroke

A

Warning sign

42
Q

What are the modifiable risk factors for stroke?

A

Smoking , diabetes, HTN, hyperlipidemia

43
Q

Ischemic strokes 2 types?

A

Thrombotic and embolic

44
Q

Thrombotic is caused by

A

Artherosclerosis

45
Q

In thrombotic: large vessels and
Small vessel is?

A

Large vessel: extracranial ( internal carotids) and intracranial (middle/ anterior cerebral artery)
Small vessel: lacunar

46
Q

What is an embolic stroke?

A

An occlusion or embolus starts inside the brain and moves to the vascular of the brain

47
Q

What is an ischemic stroke?

A

Decrease or complete blockage of blood flow to a vessel in the brain
Irreversible and neuronal death of neuron function

48
Q

What is the cause of ischemic stroke?

A

Decreased systemic perfusion, severe stenosis, or occlusion

49
Q

What are the 2 layers of ischemic stroke?

A

Ischemic/ inner core and penumbra

50
Q

Most of the medications work on what layer of the ischemic stroke?

A

The penumbra since does not die right away and can get blood form nearby arteries—-supplies nutrients and oxygen

51
Q

What is the NIH stroke scale?

A

Determines stroke severity

52
Q

What is the scoring of the NIH?

A

1-4: mild
5-14: moderate
15-25: moderate to severe
25-42: severe
Should do scale within 25 minutes on arrival

53
Q

When should you consider the stroke as ischemic?

A

If no bleeding

54
Q

What if the non-contrast ct is normal?

A

It may appear normal for an early stroke so:
Consider stroke mimics

55
Q

What are the common stroke mimics ?

A

1 migraine syndromes
2. Seizure disorders
3. Hyper/hypoglycemia

Neuro deficits won’t be permanent

56
Q

Consider if patient is an candidate for fibrinolytic?

A

Yes- give tpa within 60 minutes
No- give aspirin

57
Q

Once you rule out bleeding and mimic concerns:

A

Consider reperfusion therapy

58
Q

If you can’t rule out mimics what did you do?

A

If you have high suspicion for ischemic stroke and went through the list of mimics- then give tpa

59
Q

What is reperfusion therapy?

A

1 thrombolytics/ fibrinolytics
2 interventional therapy- endovascular

60
Q

Which tpa is fda approved?

A

Alteplase

61
Q

When to give endovascular therapy?

A

Within 6 hours and need to have large vessel occlusion
1 mechanical thrombectomy
2 aspiration thrombectomy

62
Q

What are the tpa time frames?

A

0-3 hrs: yes
3-4.5 hrs: yes but with limitations
4.5-6 hrs: wake-up

63
Q

Tpa is generally indicated for —- hrs?

A

4.5

64
Q

Tpa moa:

A

Activates plasminogen converts to plasmin then chews fibrin and breaks it down to fibrin degradation products.

65
Q

What is the modified rankin scale?

A

Determines a persons level of disability

66
Q

What is the modified rankin scale scores?

A

0: none
1: symptoms
2: slight disability
3: moderate disabilities - need help but can walk with out help
4: mod/severe disabilities - unable to walk without help
5: severely
6: dead almost

67
Q

Neuro deficits and mrs scores have no impact on mortality:

A

Tpa improved and reduced the risk of life disability after a stroke

68
Q

How long should we monitor after given tpa?

A

24 hrs for signs of hemorrhagic transformation
Risk vs benefit discussion- can sign consent but not required

69
Q

What are the contraindications for tpa?

A

Stroke is mild and non disabling
Head issues/ trauma
Cerebral infarction
Malignancies or bleeding within 21 days
Endocarditis
Aortic arch dissection
Platelet < 100,000
Inr>1.7
Aptt> 40 seconds
Pt> 15 seconds
BP> 185/110
If had lmwh in 24 hrs or Xa I in 48 hrs unless labs are normal or patient did not get a dose

70
Q

What does the aptt tell us?

A

Shows recent use of heparin or dvt prophylaxis of heparin.

71
Q

When is it beneficial if you give tpa in the 3-4.5 hr timeframe?

A

> 80 years old
History of stroke and DM
Warfarin use with inr<1.7

72
Q

What is the tpa dosing?

A

0.9 mg /kg
1 bolus: 10% of total iv push in 1 min
2 infusion of 90% in 60 min

73
Q

What are the action times?

A

Physician: 10 min
Stroke team: 15 min
Ct scan: 25 min
Interpret ct: 45 min
Needle time: 60 min

74
Q

Endovascular therapy criteria?

A

With in 6 hrs of onset
Mrs score of 0-1
Large vessel occlusion
Age 18 years old
NIHSS: >= 6
ASPECTS: >/= 6
*no perfusion imaging required

75
Q

What does ASPECTS score do?

A

Look for signs of ischemia

76
Q

How do you score ASPECTS?

A

Low score= increased signs for ischemia and greater likelihood of disability after stroke
10=normal

77
Q

Should patients receive alteplase if eligible even if thrombectomy is being considered?

A

Yes

78
Q

How do you look for large vessel occlusions?

A

Ct angiogram or magnetic resonance angiogram

79
Q

What are the limitations for endovascular therapy?

A

Few patients meet criteria and limited centers and qualified personnel

80
Q

Post stroke what is the main reason for m&m?

A

Aspiration

81
Q

When should you give aspirin in stroke patients?

A

24-48 hours post, could be given earlier if using a stent
If can’t give aspirin- use clopidogrel

82
Q

How long should DAPT be initiated?

A

21 days because with 90 there was increased risk for hemorrhaging

83
Q

When do you give DAPT?

A

Give to patients with minor non cardio embolic stroke with out tpa administration (NHSS<4) within 24 hrs of symptom onset

84
Q

What is the dosing for DAPT?

A

Clopidogrel 300-600mg loading dose then 75 mg qd, aspirin 81mg qd

85
Q

Ticagrelor not recommended why?

A

Increased risk of bleeding but could be used if clopidogrel is not an option
180mg loading then 90mg BID

86
Q

What did you do if BP is >220/110 mmHG?

A

Give treatment. Lower by 15% in 24 hr

87
Q

What if BP is < 220/110

A

Do not start treatment within 48-72 hrs = no benefits

88
Q

DVT prophylaxis?

A

Use IPC and ASA + hydration

Heparin not recommended

89
Q

How do you prevent 2’ stroke?

A

Treat their HTN, DM, dyslipidemia, Afib, carotid artery stenosis

90
Q

2’ stroke prevention guidelines:

A

Anti hypertensive- if >= 140/90 or already on meds
Antithrombotic therapy- anticoagulants for cardio embolic
strokes
Antiplatelets for atherosclerosis strokes
Statin therapy- high dose
Lifestyle- reduce alcohol

91
Q

For afib what anticoagulant?

A

DOAC > warfarin

Isbp (4 decks)

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