Stroke Flashcards
What are the types of Ischemic Stroke?
-atherosclerotic stroke
-embolic stroke
-transient ischemic stroke (TIA)
What are the types of Hemorrhagic stroke?
-subarachnoid hemorrhage
-intracerebral hemorrhage
What are the risk factors of Ischemic stroke?
-age > 55yo
-race: AA > caucasian
-sex: M>F (young) & F>M (old)
-genetics
-smoking
-HTN
-DM
-dyslipidemia
-AFib
-obesity
-cardiac disease
-physical inactivity/poor diet
What are the risk factors for Hemorrhagic stroke?
-genetics
-cerebral cavernous malformation
-bleeding disorders
-cerebral aneurysm
-HTN
-anticoagulants/antiplatelets
-trauma
What are the presentations of a stroke?
-unilateral (one-sided)
-hemiparesis
-deficits associated with specific portions of the brain
-loss of balance
-loss of vision
-one-sided weakness
-difficulty or inability to speak
-dizziness/vertigo
-headache (more common in hemorrhagic stroke)
What are the laboratory/vitals obtained for initial assessment of stroke?
-blood glucose
-INR/PT, platelets
-blood pressure
What is the imaging obtained for initial assessment of stroke?
-CT (quicker than MRI)
-CT angiogram (CTA)
-carotid doppler, ECG, TTE
What NIH Stroke Scale constitutes a mild stroke?
1-5
What are the goals of therapy of stroke treatment?
-reduce ongoing neurologic injury
-reduce mortality
-reduce long term disability
-prevent complications
-prevent reoccurrence of stroke
What are the pharmacological treatment options for acute management of ischemic stroke?
-thrombolytic
-endovascular therapies
-aspirin
-other (BP control, VTE prophylaxis, core measures)
What is the MOA of thrombolytics?
initiates fibrinolysis by binding to fibrin in the clot and converts entrapped plasminogen to plasmin
What drugs are Thrombolytics?
-Alteplase
-Tenecteplase
What are the monitoring parameters when utilizing thrombolytic therapy?
-neurological assessments (Q15min during first hour)
-BP
-signs and symptoms of bleeding
What NIHSS score would be appropriate to treat with thrombolytics?
> 5 (not mild stroke)
How many hours after symptom onset do thrombolytics need to be administered?
4.5h, 3h ideal
What are some of the requirements of using thrombolytics?
- > 18 yo
-BP < 185/110mmHg
-CT ruled out hemorrhage
-blood glucose > 50mg/dL
What are the absolute contraindications for using thrombolytics?
-SAH or ICH on imaging or signs and symptoms
-use of DOAC in past 48h
-use of warfarin or LMWH 24h prior
-infective endocarditis
-intra-axial, intracranial neoplasm
-aortic arch dissection
-active bleed
-coagulopathy
-severe head trauma in last 3 months
-GI bleed or malignancy prior 21d
What is the Thrombolytic Assessment Checklist?
- time (within 4.5h)
- severity (moderate-severe stroke, NIHSS > 5)
- blood pressure BP < 185/110mmHg
- blood glucose > 50
- contraindications
What are the complications of thrombolytics?
bleeding, intracranial hemorrhage
What is a thrombectomy?
vascular procedure to remove clot causing infarction (acute management)
What is a carotid endarterectomy?
surgical removal of artherosclerotic plaque in carotid arteries (secondary prevention)
What is the treatment dose of Aspirin for stroke?
-no thrombolytic= 160-325mg, given as soon as possible
-thrombolytic= 160-325mg, given 24h after thrombolytic
What is permissible BP in a pt that does not receive a thrombolytic?
<220/120 mmHg
What acute blood pressure agents may be administered?
-labetalol
-nicardipine
-clevidipine
What is VTE prophylaxis protocol?
-thrombolytic= 24h after thrombolytic given
-no thrombolytic= day 1 of admission
What drugs can be given for VTE prophylaxis?
-heparin 5000 units SQ Q8-12h
-enoxaparin 30mg SQ BID
-enoxaparin 40mg SQ daily
What is the first line antiplatelet therapy for secondary prevention of ischemic stroke?
aspirin 50-81mg daily
What is the indication of P2Y12s?
-clopidogrel= could be monotherapy or in combo with aspirin in minor stroke (NIHSS score 3 or less) or high risk TIA
-ticagrelor= only in combo with aspirin in minor stroke (NIHSS < 5) or high risk TIA
What are the adverse effects of P2Y12s?
-hemorrhage
-bruising, hematoma
-epistaxis
-additional SE of ticagrelor: dyspnea, increased uric acid, increased SCr
What should be avoided while taking Clopidogrel?
CYP2C19 inhibitors (omeprazole) decrease metabolism of clopidogrel
Which P2Y12 is contraindicated in history of stroke?
prasugrel
Which P2Y12 is not indicated in stroke?
cangrelor
What is the indications of Dual Antiplatelet Therapy (DAPT)
minor strokes or high-risk TIA
What is the recommended statin therapy for secondary prevention of stroke?
high intensity statin= atorvastatin 40-80mg or rosuvastatin 20-40mg
What is the treatment protocol for Hemorrhagic stroke?
anticoagulation reversal!
-warfarin= vit K, prothrombin complex concentrate
-heparin= protamine
-dabigatran= idarcizumab
-apixaban, rivaroxaban, edoxaban= andexanet alfa
may also treat any clinical seizures or BP
