Stroke Flashcards
What are the types of stroke?
Acute ischemic stroke, AKA non-cardioembolic stroke
* Caused by a thrombus that forms during a cerebral atherosclerotic infarction
Cardiembolic stroke
* Occurs when an embolus forms in the heart and travels to the brain
* Common cause is Afib
Hemorrhagic strokes
* Bleeding in the brain
Risk Factors
- HTN
- Afib
- Gender (females > males)
- Ethnicity (highest in African Americans)
- Age >=55 years
- Atherosclerosis
- DM
- Prior stroke or TIA
- Smoking
- Dyslipidemia
- Patent foramen ovale (PFO)
- Sickle cell disease
TIA vs Stroke
- TIA, sometimes called “mini-stroke” is caused by a temporary clot, or block of blood flow, in the brain
- Sx of TIA are same as stroke, but disappear on their own within minutes to a few hrs
- There is no permanent damage
- Seek immediate medical attention; TIAs are often a warning for a future full stroke
S/Sx and Diagnosis of stroke
ACT F.A.S.T
Face:
* Ask person to smile. Does one side of the face droop or numb? Is the smile uneven?
Arms:
* Ask the person to raise both arms. Does one arm drift downward?
Speech:
* Ask the person to repeat a simple sentence. Are the words slurred? Is the sentence repeated correctly?
Time:
* If the person shows any of the sx, even if they go away, call 911 asap
Diagnosis: Brain imaging using CT
Alteplase
- Cause clot breakdown by binding to fibrin and converting plasminogen to plasmin, resulting in fibrinolysis
- Only FDA-approved fibrinolytic drug for acute ischemic stroke
- Patients are candiates if clot is confirmed
- It can be administered within 3 hrs of sx onset
- It can be administered within 4.5 hrs of sx onset in select patients
- BP should be <185/110 BPM
Alteplase
Cathflo Activase
Alteplase (Activase) - Recombinant tissue plasminogen activator
Tenecteplase (TNKase)
* CIs: active internal bleeding, Hx of recent stroke, severe uncontrolled HTN (BP >185/110), Tx dose of LMWH, use of a direct thrombin inhibitor or direct factor Xa inhibitor, INR >1.7
- SEs: bleeding (including ICH)
- Monitoring: Hgb, Hct, s/sx of bleeding, neurological assessments and BO
0.9 mg/kg (maximum dose 90 mg)
Must rule out intracranial hemorrhage before use
Aspirin
162-325 mg PO within 24-48 hrs after stroke onset
Tx of modifiable risk factors -HTN
- ACE inhibitors and thiazide-type diuretics
- BP goal: <130/80
Tx of modifiable risk factors - Dyslipidemia
High-intensity statin
Tx of modifiable risk factors - Afib
Cardioembolic stroke due to Afib requires anticoagulation
Tx of modifiable risk factors - Lifestyle modifications
- Na restriction
- BP reduction
- Mediterranean-type diet
- Weight reduction: BMI 18.5-24.9 and waist <35 inches for women and <40 inches for men
Antiplatelet Tx
- Non-cardioembolic stroke: reduce the risk of recurrent stroke
- Aspirin is recommended within 24- 48 hrs after onset. Clopidogrel is used when aspirin is contraindicated
- Aspirin and clopidogrel combination can be initiated within 24 hrs of minor ischemic stroke and continued for 21 day, followed by clopidogrel monotherapy
- The combination should not be used long-term for secobdary prevention of stroke or TIA due to the hemorrhage
- There is no added benefit to increasing the aspirin dose
Antiplatelet Drugs
Aspirin
- Bayer, Bufferin, Ecotrin: 50-325 mg daily
- CIs: salicylate allergy; children an teenagers with viral infection due to the risk of Reye’s syndrome
- Warnings: bleeding, tinnitus
- SEs: dyspepsia, heartburn, bleeding
Notes: PPIs may be used to protect the gut; consider the risks (decreased bine density, increased infection risk)
Antiplatelet Drugs
ER dipyridamole/aspirin
- Aggrenox
- Warnings: hypotension
- SEs: headache
Notes: not interchangeable
Antiplatelet Drugs
Clopidogrel
- Plavix: 75 mg daily
- BW: test to check CYP2C19 genotypento reduce cardiovascular events
- CIs: serious bleeding
- Warnings: bleeding risk; stop 5 days prior to elective surgery, do not use with omeprazole or esomeprazole, TTP
