Stroke Flashcards
Pathophysiology
Ischemic Stroke
Types: cardioembolic vs non-cardioembolic?
Blood clots (thrombus) block blood flow to brain
Thrombus usually formed by cerebral atherosclerotic infarction
Cardioembolic: clot forms in heart and travels to brain
* Common cause: atrial fibrillation
Non-cardioembolic: clot forms in brain, not the heart
Acute treatments for Ischemic Stroke?
- Fibrinolytics
- Blood pressure control (if tPA not given)
- Other treatments (antiplts, HTN management, hyperglycemia, DVT ppx)
Acute treatments for Ischemic Stroke
Fibrinolytics
Medications and dosing?
- Alteplase 0.9 mg/kg (max: 90 mg); 10% given IVP over 1 min, then 90% given IV infusion over 1 hour
- TNKase 0.25 mg/kg (max: 25mg) IVP over 5 seconds; flush with NS
Acute treatments for Ischemic Stroke
Fibrinolytics
tPA exclusions
Not hemorrhagic stroke
No active bleed – in non-compressible areas
No INR >1.7
No prior stroke/TIA (within 3 months)
No prior head trauma (within 3 months)
No BP >185/110
No LMWH within 24h OR DOAC within 48h
Acute treatments for Ischemic Stroke
Fibrinolytics
tPA exclusion; BP control for BP >185/110
BP control (maintain BP <180/105)
*Labetalol 10-20 mg IV push over 1-2 minutes
*Nicardipine 5 mg/hr IV infusion
Clevidipine 1-2 mg/hr IV infusion
Acute treatments for Ischemic Stroke
Fibrinolytics
tPA inclusion
Within 4.5 hours from symptom onset
Within 60 minutes (door-to-needle)
Acute treatments for Ischemic Stroke
Blood pressure control
Permissive HTN: 220/120
MD will allow BP < 220/120 and hold/decrease meds up to 48 hrs after stroke
Rationale: increase BP, increase blood flow/perfusion
Acute treatments for Ischemic Stroke
Other treatments: antiplatelets
- Aspirin 160-325 mg AFTER 24 hours of tPA, but within 48 hours of stoke onset
- Clopidrogel 300-600 mg
- Short-term DAPT (ASA + Plavix) – indicated for patients with TIA or acute ischemic stroke who can swallow and do not have a known cardioembolic source of presentation
Acute treatments for Ischemic Stroke
Other treatments: Hypertension management
Goal: <185/110
Maintain <180/105
Medications: labetalol, nicardipine, clevidipine
Acute treatments for Ischemic Stroke
Other treatments: Hyperglycemia management
Goal: 140-180 mg/dL
Acute treatments for Ischemic Stroke
Other treatments: Deep Vein Thrombosis (DVT) prevention
Intermittent Pneumatic Compression (IPC) devices – squeeze legs to increase blood flow
Medications: UFH, LMWH (only after 24h of receiving alteplase)
Secondary Prevention (outpatient) for Ischemic Stroke?
- Hypertension
- Dylipidemia
- Afib management – for cardioembolic
- Antiplts – for non-cardioembolic
Secondary Prevention for Ischemic Stroke
Hypertension management
Goal: BP <130/80
ACEi and thiazide-type diuretics
Secondary Prevention for Ischemic Stroke
Dyslipidemia
Goal: LDL >70
High-intensity statins – Lipitor 40-80 mg, Crestor 20-40 mg
Secondary Prevention for Ischemic Stroke
Atrial fibrillation
for cardioembolic
Anticoagulants
Secondary Prevention for Ischemic Stroke
Antiplatelets
for non-cardioembolic
- Aspirin
- DAPT – aspirin + clopidogrel
- Aspirin/dipyridamole (Aggrenox)
- Cilostazol (Pletal)
Pathophysiology
Hemorrhagic Stroke
Brain bleed due to ruptured blood vessel
Two types: (1) intracranial, (2) acute subarachnoid
Intracranial etiology: ↑ intracranial pressure (ICP)
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
UFH, LMWH, warfarin, anti-Xa , Pradaxa, argatroban (just antidote)
Heparin –> protamine
LMWH –> Andexxa, protamine
Warfarin –> vit K, Kcentra (w/ vit K), fresh frozen plasma (FFP), Novoseven RT
Apixaban, rivaroxaban –> Andexxa
Pradaxa –> Praxbind
Management of Hemorrhagic Stroke
- reversal of anticoagulants
- IV fluids (+ elevate head 30 deg)
- anticonvulsants – only for seizure tx, NOT ppx
- Non-invasive cerebral angiogram
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Protamine dose for UFH
1 mg of protamine for each ~100 units of heparin
* Since UFH has a very short half-life (1-2 hours), reverse the amount of heparin given in the last 2-2.5 hours
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Protamine dose for LMWH (enoxaparin, dalteparin)
Enoxaparin
Within 8 hours: 1 mg protamine per 1 mg
> 8 hours ago: 0.5 mg protamine per 1 mg
Dalteparin
1 mg protamine for each 100 anti-Xa units
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Andexxa doses (high and low) for LMWH
High dose: 800 mg IV bolus at 30 mg/minute over 30 minutes, followed by 960 mg IV infusion at 8 mg/minute for up to 120 minutes
Low dose:
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Vitamin K indication and dose for warfarin
1-10 mg PO/IV
Avoid SQ and IM
IV must be SLOW IV infusion and diluted
* BBW: hypersensitivty, anaphylaxis, SE: hypotension
If no significant/major bleeding → PO
* INR >10 WITHOUT bleeding –> 2.5-5mg PO
If serious bleeding → IV infusion (NEVER PUSH) AND Kcentra
* Major, life-threatening bleed –> 5-10 mg SLOW IV injection
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
KCentra indication and dose for warfarin
Indication: severe bleeding
Factors 2, 7, 9, 10
ALWAYS administer with vitamin K
Dosing based on body weight and INR
Do not repeat dose
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Andexxa for factor Xa inhibitors
IV bolus, followed by infusion
Dosing is specific to the Xa inhibitor, the dose and when the last Xa inhibitor dose was taken
Management of Hemorrhagic Stroke
Reversal of Anticoagulants
Praxbind for Pradaxax
5 g IV
give (2) 2.5 g doses no more than 15 min apart
Management of Hemorrhagic Stroke
IV Fluids
(and elevate head 30 degrees)
Rationale: ↓ ICP
Mannitol
Hypertonic saline (3% NS)
Management of Hemorrhagic Stroke
Non-invasive cerebral angiography
computed tomography angiography (CTA)/magnetic resonance angiography (MRA) within 48 hours of onset should be considered for all patients
Pathophysiology
Subarachnoid Hemorrhage (SAH)
cerebral aneurysm rupture → sx include severe headache
Management of Subarachnoid Hemorrhage (SAH)?
Nimodipine 60 mg PO q4hr
* Rationale: prevent vasospasm (usually occurs 3-21 days after the bleed)
* DHP CCB that is more selective for cerebralk arteries due to increasewd lipophilicity –> only indicated for SAD
* BBW: NO IV, causes life-threatening adverse events (e.g. hypotension)
* If it cannot be swallowed, puncture and withdraw contents of the capsule with a parenteral/needle syringe –> transfer to oral syringe to be administed through a nasogastric tube
