Stroke Flashcards by Jordan Cyr

What is a stroke?

sudden onset of FOCAL neurologic deficit resulting from the interruption of blood flow to an area in the brain

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What are some symptoms of stroke?

hemiplegia
hemiparesthesia
blindness in one eye
speech disturbance
dizziness
weakness
headache
confusion

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What is the acronym to remember the signs of stroke?

FAST
face drooping?
can you raise both arms?
is speech slurred?
time to call 911

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What is the leading cause of disability?

stroke

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Do people recover from stroke?

function may improve slowly over days-months

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What is TIA?

transient ischemic stroke
focal neurologic deficit as a result of ischemia lasting less than 24hrs WITHOUT evidence of infarction on imaging studies

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Is hemorrhage a likely cause of TIA?

no
hemorrhage stroke is unlikely to resolve itself within 24hrs

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What are the chances of experiencing a stroke in the future if you had TIA?

7.5-17% within 3 months

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If a person experienced TIA, how are they now considered?

now considered as secondary prevention

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What are the types of stroke?

hemorrhagic (13%):
-higher death rate
-higher morbidity
-risk: aneurysm, HTN, medications (DAPT, OAC)
ischemic (87%):
-20% atherosclerosis
-30% cryptogenic
-20% cardioembolic
-25% lacunar
-5% other causes

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What are conditions that can result in thrombus generation within or on the heart?

atrial fibrillation
mechanical heart valves

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Describe cardioembolic stroke.

thrombi can break off and travel through aorta–>carotid artery–>small cerebral vessels

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What are medications used to prevent cardioembolic stroke?

anticoagulants
-warfarin
-dabigatran
-rivaroxaban
-apixaban

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What is the first decision that will be made in ER after someone has been diagnosed with stroke?

is the person eligible for thrombolytics?

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What are the recommendations for the use of thrombolytics and stroke?

IV tPA is recommended provided that treatment is initiated within 3 hours of clearly defined symptom onset
therapy is also recommended between 3-4.5hrs of stroke except: >80yrs, OAC, severe stroke, history of stroke, diabetes
ASA usually delayed until 24hrs after tPA

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What do plasminogen activators do?

convert plasminogen to plasmin
plasmin degrades fibrin into soluble products

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What are examples of plasminogen activators?

alteplase (tPA)
-exact human sequence
-requires 1hr infusion time
tenecteplase
-longer acting fibrinolytic
-administered with one IV bolus dose
-recently shown “non-inferior” to tPA

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What are the outcomes with the use of fibrinolytics in acute stroke?

if administered within 3-.4.5hrs will reduce risk for poor outcomes (disability, lack of recovery, neuronal damage)
if administered later, outcomes are not lower

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Why is there explicit eligibility criteria for tPA?

due to the risk of bleeding

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What is the eligibility for tPA?

clearly defined onset within past 3hrs
significant neurologic deficit

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What are the contraindications to tPA?

rapidly improving
hemorrhage on CT
seizure at stroke onset
recent stroke or head injury (3 months)
recent GI/UTI bleed (3 weeks)
bp>185/110
low platelets
recent anticoagulation (2 days)
history of ICH

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True or false: it is common to see tPA administered alongside an anticoagulant for stroke

false

What are the recommendations if someone is not eligible for tPA?

antiplatelet therapy is initiated
anticoagulation would be used instead for cardioembolic stroke
if hemorrhage has been ruled out

What are examples of antiplatelet agents?

COX inhibitors: ASA
ADP inhibitors: clopidogrel, prasugrel, ticagrelor
interference with cAMP: dipyridamole/ASA
GP IIb/IIIa antagonists

True or false: GP IIb/IIIa antagonists have no role in stroke

true

True or false: Aggrenox (dipyridamole/ASA) has a role in MI

false studied in post-stroke

What is the antiplatelet of first choice in most cases when a person is ineligible for tPA?

ASA

Describe the pathway of arachidonic acid.

arachidonic acid can become COX-1 or COX-2 COX-1 produces thromboxane A2 COX-2 produces prostacyclin

How does ASA compare to other NSAIDs?

ASA is irreversible little effect on COX-2 at low doses

How much does ASA reduce the risk in secondary prevention of stroke?

16%

ASA is used in secondary prevention of stroke in all patients, except who?

certain patients with afib/cardioembolic risks hemorrhagic stroke other CIs

What is the incidence of GI bleeds from ASA?

0.4% per year

What will put an individual at a greater risk of GI bleed from ASA?

higher dose (can occur with low doses) hemostatic defect (hemophilia/low platelets) previous GI bleed drugs (anticoagulants) age >60 uncontrolled HTN CKD

True or false: ADP inhibitors do not cause GI bleeding, only NSAIDs do

false

What are the effects of prostacyclin (PgI2)?

inhibit acid secretion enhance mucosal blood flow promote secretion of cytoprotective mucous

What are the guidelines for antiplatelets in non-cardioembolic stroke (2ndry prevention)?

acceptable 1st line agents: -aspirin 50-325mg OD -Aggrenox BID reasonable 2nd line therapy: -clopidogrel 75mg OD ASA+clopidogrel for first 21 days followed by ASA alone -considered for 21 days in patients with minor stroke -long term use is not recommended

What is dipyridamole?

MOA is controversial (PDE inhibitor or adenosine inhibitor or promoter of PGI2) poor absorption from regular dosage forms Aggrenox has modified release formulation

True or false: Aggrenox is possibly superior to ASA alone for secondary prevention of stroke

true RRR 18% vs ASA

How frequently is Aggrenox administered?

BID (200mg/25mg)

Are ticagrelor or prasugrel recommended in stroke guidelines?

not currently recommended in stroke guidelines evidence is emerging not covered by Sask drug plan for stroke indication much more costly than ASA 81mg OD

Describe low-dose ASA in secondary prevention of stroke based on the following: efficacy, safety, DI, convenience, CI, cost

efficacy: -moderate effectiveness from RCT (may be slightly less effective than Aggrenox) -also indicated for prevention of ACVD events -NOT very effective for cardioembolic conditions safety: -nuisance bleeding/bruising (common but not dangerous) -major bleeding (mostly CNS or GI) -GI bleeding in 0.4% in healthy, risk increases with disease/age -GI bleed/ulceration often not painful -CNS bleeding typically 1/10 of major bleeding (less common but more dangerous -at low doses, does not exhibit renal/bp effects of NSAIDs DI: -other antiplatelets/anticoagulants/NSAIDs/SSRIs -methotrexate lvls increase with ASA but not likely 81mg convenience: -OD dosing but half life is short CI: -prior bleed -uncontrolled HTN -bleeding risk (low platelets, bleeding conditions, age) cost: -cheapest antiplatelet available

What is the role of DAPT in stroke?

used in: -non disabling stroke -high risk TIA ASA+clopidogrel given within 24hrs and continued for 21 days *reduces 90d stroke risk from 7.8% to 5.2%*

What are stroke patients at risk for and why?

venous thromboembolism due to paralysis/immobility all patients with reduced mobility are given preventative therapy (low dose heparin, LMWH, IPC/ES)

What is the worst possible outcome of VTE?

pulmonary embolism

What are the recommendations around blood pressure control and stroke?

acute phase (onset to 72 hours): -only extreme bp values are treated (>220/120) -if thrombolysis is considered and bp >185/110

What are the current guidelines of treating blood pressure post-stroke?

strong consideration for treating everyone post-stroke regardless of bp threshold bp>140/90 target <140/90 FIRST LINE: ACEI + TZD

What is the medication regimen of a patient for secondary stroke prevention?

blood pressure: ACEI+TZD (goal<140/90) antiplatelet therapy statins smoking cessation (RRR 33%) and lifestyle intervention

Is antiplatelet therapy or anticoagulant therapy preferred for atherosclerotic stroke management?

antiplatelet therapy: -showed lower risk of death or recurrent stroke at 2 yrs, major bleed over 2 yrs, and any bleed over 2 yrs

When would warfarin or anticoagulants be used for stroke?

cardioembolic stroke

What is a common consequence of afib?

stroke thus, almost all patients will receive stroke prevention even if they have never had a stroke

What is the only group of patients that will receive primary prevention for stroke?

afib

Describe the recommendations of primary prevention of stroke for afib.

CHADS-65-->OAC (have one of the following): -CHF (heart failure) -hypertension -age 65 -diabetes -prior stroke or TIA none of the above: -CAD or PAD-->antiplatelet none of the above-->no antithrombotic

True or false: we use primary prevention of stroke or heart with ASA in virtually all patients

false

What is the regimen of secondary stroke prevention?

ABCKDE antiplatelets blood pressure (ACEI + thiazide) cholesterol (statins) diabetes exercise/lifestyle/diet (RRR 33%)