Stroke Flashcards
Transient ischemic Attack (TIA)
-Focal Neurologic deficit for how long, without ___?
-Results from Temporary interruption of ?
-Associated with ?
STROKE
-Focal neurologic deficit for how long?
-Persistent ischemia leads to ?
-Two types of stroke?
< 24 hrs, without acute infarction
-Cerebral blood flow
-INCR stroke risk
> 24 hrs
-Neronal death
-Ischemic (87%) vs hemorrhagic stroke (13%)
Risk factors for ISCHEMIC Stroke :
1. Non modifiable?
2. Potentially modifiable?
3. MODIFIABLE ?
- Age, race,sex, low birth weight, genetics
- Migraine, metabolic syndrome, drug and alc abuse, inflamm and infection, elevated lipoprotein, homocysteinemia, sleep disordered breathing
- -Smoking
* Hypertension
* Diabetes
* Asymptomatic carotid stenosis
* Dyslipidemia
* Atrial fibrillation
* Sickle cell disease
* Poor diet
* Obesity
* Physical inactivity
* Other cardiac diseases (CAD, HF,
PAD
Stroke Recognition :
Signs (BEFAST) (5)
- losing Balance or coordination , trouble walking
- Trouble seeing out of one or both Eyes
- Face –> one side of face will droop
- Arms –> one arm will drift down
- Speech –> words will slur, words hard to come out
Time –> if person shows any of these sx’s call 911 immediately and get to hospital as brain cells are dying
Stroke Clinical Presentation
- Sx’s ? N,C,T,D,S
- signs (H,H,V,D,A,D,V,A)
- numbness/weakness in face, arms, legs
- confusion, trouble speaking, or understanding speech
-trouble seeing
-dizziness, balance loss, unable to walk
-severe headache - Hemiparesis or monoparesis
-hemisensory deficit
-Vertigo
-double vision
-aphasia
-dysarthria
-Visual field deficits
-altered levels of consciousness
Diagnostic Testing ? (4)
What does it mean when you see white on a non contrast CT scan? What if its dark?
- Non-contrast CT Scan (can take 24 hrs to show ischemic infarction)
- CTA
- ECG/TTE (is pt in afib , or have valve problems)
- MRI (will reveal infarct within mins)
White = BLEED (Hemorrhagic)
Dark = Ischemic
NIHStroke SCALE or NIHSS
State the stroke severity of each NIHSS Score
1. 0
2. 1-4
3. 5-15
4. 16-20
5. 21-42
- No stroke sxs
- minor stroke
- moderate stroke
- moderate to severe stroke
- severe stroke
General Supportive Care /Emerg Tx :
Acute Management : What 6 aspects?
Secondary Prevention (4)
- Supplemental Oxygen to keep O2 sat > 94%
- BP management **
- Temperature
- blood glucose
- IV fibrinolytics (Within 60 mins) **
- mechanical thromboectomy
- antiplatelets
-anticoags
-statins
-BP control
Alteplase (t-PA)
1. Age?
2. NIHSS score of?
3. HEAD CT is Negative for?
4. Blood glucose
5. BP?
6. Clearly defined onset of sx’s how long from treament?
7. Door to needle time?
- > =18 yrs
- > 5
- Bleed
- 50-400 mg/dL
- < 185/110 mmHg
- < 4.5 hrs from treatment
- 60 mins!
Alteplase CI’s –> See Slide 23 on stroke lecture
See Chart
Alteplase (t-PA)
1. Dose? ** On exam forsure
-Bolus
-Infusion
-use ___
- AE’s (2)
- Monitoring ? (4)
- 0.9 mg/kg max of 90 mg
- Bolus 0.09 mg/kg (10%) as IV bolus over 1 min (Max 9 mg)
-Infusion 0.81 mg /kg (90%) as infusion over 1 hr (max 81 mg)
-ACTUAL BODY WEIGHT - Bleeding
-Angioedema (rare) - Neuro exam,
-BP ,
-risk factors or signs of bleeding : severe HA, HTN, Nausea
-Recheck HEAD CT in 24 hrs
Management of ICH within 24 hrs after IV Alteplase
1. Stop ___
2. LABS? (5)
3. Emergent non contrast ___
4. Which blood product ?
5. medications? (2)
6. ____ consultation ?
7. Supportive therapy such as ?
- Alteplase infusion
- CBC, PT/ INR, aPTT, fibrinogen level, type and cross match for PRBCs
- HEAD CT
- Cryoprecipitate
- Tranexamic acid (TXA) or AMINOCAPROIC acid
- Hematology and neurosurg
- BP control, ICP, CPP, MAP, temp, glucose
BP CONTROL : AIS (< 72 h from sx onset) and elevated BP
Pt qualifies for IV thrombolysis therapy ?
- YES
- NO
A. If BP < 220/110
B. If BP > 220/110
- Lower SBP to < 185 and DBP < 110 before initiation of IV thrombolysis AND
Maintain BP < 180/105 for first 24hrs after IV thrombosis
2A. Dont rlly do anything, but if they have preexisting HTN, reinitiate anti htn drugs after neuro stability
2B. Lower BP 15% during first 24 hrs
AIS : BP Medications
- What three can u use?
-Whats the primary agent ? - What should you avoid?
- Labetalol 10-20 mg IV over 1-2 mins
-Nicardipine 5 mg/hr IV , titrate by 2.5 mg/hr q5-15 mins
-Clevidipine
Nicardipine , but labetalol is much easier to use!
- NITROPRUSSIDE
Acute Ischemic Stroke Summary :
1) Acute managament
a. if the goal is to achieve reperfusion, what two options do u have?
b. Other reccs to control ___, target glucose of __, avoid hypoglycemia of ____ , use __ vs ___ ,
use __
1a. tPA (onset < 3-4.5 hrs)
-Mechanical thrombectomy (<6-24hrs)
b. BP, 140-180, < 60, antiplatelet vs anticoag , statins
AIS : Secondary Prevention ANTIplatelets
- recommended in ALL pt’s with ____ ***within ___ after onset
- Aspirin Dose?
if no Tpa given start when ?
if tPA given, start when?
-Avoid use with ? - Aggrenox (Dipyridamole ER 200 mg + aspirin 25 mg )
Dose?
ADE’s ? - Clopidogrel (can use if recurrent stroke on ASA)
Dose?
AE’s? (2)
- NON-CARDIOEMBOLIC ISCHEMIC STROKE , 24-48 hrs
- 81-325 mg/day
-within 48 hrs of sx onset
-24-48 hrs after t-PA
-NSAIDS - 1 capsule PO BID
- HA’s! , less GI bleeding than aspirin - 75 mg PO DAILY
-Diarrhea and rash
AIS : 2ndary prevention ANTICOAGS
- Criteria for using Anticoags?
- Recommended OACs for pt’s with ___ and a CHADSVASC score of ?
- DOACS rec over warfarin in eligible pt’s EXCEPT in which cause should u ONLY use warfarin ?
- CARDIOembolic Ischemic stroke
- AFIB, >=2 for men and >=3 for women
-Start 4-14 days after stroke sx onset - mod-severe mitral stenosis, or pt’s with mechanical heart valves
AIS : Secondary Stroke Prevention of BP Control *
Stroke >= 72hrs from sx onset and stable neuro status or TIA –>
Previously diagnosed or treated hypertension?
- If YES
-What should u do? and whats the BP goal? - if NO
A. Established SBP >=140 or DBP >=90?
-What should u do, and what BP GOAl?
B. Established SBP < 140 and DBP <90?
- What should u do? - You can recc ___ mods, or use medications such as?
-Resume or initiate these drugs WHEN?
- Restart Antihypertensive tx
-Aim for BP < 130/80
2A. Initiate antihtn tx
-aim for BP < 130/80
2B. Starting antihtn drugs not useful!
- lifestyle
- Diuretics +/- ACEI’s or ARBS
-AFTER SEVERAL DAYS
AIS 2ndary Prevention : STATINS
- What class of statins to start ?
CI if ? (2)
Start when oral meds tolerated - if on max statin and LDL >= 70, what can u add?
- You can add on ___ after the previous agent
- HIGH INTENSITY or maximal statin (Lipitor 40-80 mg or rosuv 20-40 mg) –> renal dose for crestor if ClCr< 30 use 5-10 mg daily
-Acute liver disease or preg/nursing
- Ezetimibe
- PCSK9-I
Hemorrhagic Stroke : Intracerebral hemorrhage (ICH) (10% stroke cases)
- What happens?
- Neuro deficit progresses over ___ to ___
- SX’s? (4)
- Blood vessel within brain ruptures
- Minutes to hours
- HA
Vomiting
incr BP
Altered level of consciousness
ICH Risk Factors
H,A,S,I,C,A,T,A
If the ICH is warfarin induced what reversal agents can you give? (3)
If ICH is Dabigatran induced use?
If ICH is Xarelto or Eliquis induced?
-BBW for ?
For Andexanet Alfa, when would u give high dose vs low dose?
a. Eliquis
b. Xarelto
HTN
Alcohol abuse
Smoking
incr age
cocaine
Amphetamines
trauma
Anticoags!
- Vitamin K (5-10 mg IV) , FFP (10-15 mL/kg IV) , K centra 4 factor PCC (25-50 units/kg IV)
- Praxbind (Idarucizumab)
- Andexxa (Andexanet alfa)
-thromboembolic risk
a. give low dose if last dose was >= 8 hrs and if dose of eliquis was <=5.
High dose if last dose >=8 hrs and if dose of eliquis >5 or unknown.
b. Same as above ^ but for xarelto dose its 10 mg
ICH : management of HTN (During time of stroke)
If it is acute spontaneous ICH (< 6 h from sx onset) and…
1. SBP is 150-220 mmhg ….what should SBP NOT be lowered to ?
- If SBP > 220 mmHG? lower SBP with ?
- Do not lower SBP to < 140 mmHG!
- Continuous IV infusion and close BP monitoring
ICH : Secondary Prevention
1. Initially, hold all ___
- consider starting ___ within 1-4 days
-Hold antiplatelets for how long after bleed?
-Hold warfarin or DOACS for how long in pts without mechanical heart valves?
- COnsider BP of?
- Avoid __ and ___
- Avoid (Sugar)
- Blood thinners
-VTE prophylaxis
->= 1-2 weeks
->=4 weeks - < 130/80
- alcohol (> 2 drinks/day) , tobacco
- hyper or hypoglycemia
Subarachnoid Hemorrhage (SAH) (3%)
- What happens?
- Most common cause?
- SX”S? (5)
- Blood vessel just outside of brain ruptures and blood pools in subarachnoid spaces
- Traumatic head injury , Intracranial aneurysm rupture
- Sudden intense headache (worst headache ever)
-Stiff neck
-nausea
-vomiting
-loss of consciousness
SAH RISK FACTORS
H,A,S,I,C,F,W,R
SAH COMPLICATIONS : State what methods to treat
- Re-bleeding
- Hydrocephalus
- vasospasm
HTN
Alcohol abuse
smoking
incr age
cocaine
family hx of SAH
women
race
- Rebleeding
-surgical clipping or endovascular coiling - Ventricular drain or shunt
- Nimodipine or Mag sulfate
