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PHRM 864 Module 4 > Stroke > Flashcards

Stroke Flashcards

1
Q

Stroke is

A

an acute focal injury due to lack of blood/oxygen to the central nervous system causing neurological deficits

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2
Q

Types of stroke

A

ischemic: cardioembolic or atherosclerotic
hemorrhagic

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3
Q

Ischemic stroke

A

an infarction of brain tissue resulting from compromised blood flow
atherosclerotic ischemic stroke (build up of plaque) nad cardioembolic ischemic stroke (embolus, due to Afib)

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4
Q

Hemorrhagic stroke

A

bleeding in the brain due to rupture of a cerebral artery; not getting to other areas of vasculature system

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5
Q

Pathophysiology of atherosclerotic stroke

A

partial or full occlusion from cholesterol plaque buildup –> blood clot blocks artery –> decrease in amount of blood to brain
platelet and lipids are primary targets

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6
Q

Pathophysiology of cardioembolic stroke

A

atrial fibrillation in left atrium

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7
Q

Pathophysiology of hemorrhagic stroke

A

aneurysm in cerebral artery breaks open, causing bleeding around brain; pressure of blood on brain causes brain tissue death

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8
Q

Stroke risk factors

A

non-modifiable: age, family history, females, race, low birth weight, sickle cell disease
modifiable: CV diseases (Afib, valvular diseases), diabetes, hyperlipidemia, HTN, illicit drug/alcohol abuse, obesity/physical inactivity, cigarette smoking

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9
Q

Clinical presentation: FAST

A

face drooping
arm weakness
speech difficulty
time to call 911

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10
Q

Clinical presentation

A

dysphasia (difficulty speaking), facial droop, unilateral/bilateral weakness, ataxia (inability to coordinate muscle movement), vision changes (diplopia), HA (more common with hemorrhagic)

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11
Q

Symptom evaluation

A

timing of sx onset
NIHSS score 0-42 with increased scores meaning worse prognosis

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12
Q

Assessment

A

imaging
labs
vital signs
tests

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13
Q

Assessment: imaging

A

head CT or MRI - look in brain to see if there’s an active bleed or occlusion

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14
Q

Assessment: vital signs

A

blood pressure
oxygen saturation (<90, give O2)

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15
Q

Assessment: labs

A

blood glucose
basic metabolic panel
complete blood count
hematologic markers: INR, aPTT

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16
Q

Assessment: tests

A

ECG (looking for Afib)
echocardiogram
if ischemic stroke with Afib or valvular abnormalities, usually cardioembolic; if ischemic stroke with normal sinus rhythm, usually atherosclerotic

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17
Q

Goals of treatment for acute stroke

A

limit extent of neurologic injury and long-term disability
decrease mortality
prevent future strokes

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18
Q

Gylcemic control

A

hypoglycemia: can cause neurological changes mimicking a stroke; treat with carbs to maintain euglycemia
hyperglycemia: in setting of acute stroke, elevated BG (>180 mg/dL) has resulted in worse morbidity and mortality; treat with SC insulin to maintain BG < 180 mg/dL while inpatient (only use insulin drip if pt in acidosis)

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19
Q

Medication access

A

due to physiologic changes after a stroke, pts must be evaluated for their ability to swallow
if NPO, utilize alternate route: IV, topical, rectal, feeding tube

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20
Q

Acute blood pressure management

A

argument for reducing blood pressure: minimize long-term neurological deficits, decrease risk of cerebral edema and hemorrhagic transformation, prevention of early recurrent stroke
argument against reducing blood pressure: dropping BP too quickly can limit brain perfusion which can worsen ischemia and neurologic fx
BP control after a stroke requires a balance

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21
Q

Acute blood pressure goals

A

check BP q15min x 2hr than q30min x 6hr then q1hr for 16hr
BP goals within first 48 hours: higher than normal BP goals to allow permissive HTN
no tPA: <220/110 mmHg
tPA given: <180/105 mmHg (lower goal b/c tPA risk factor is bleeding –> higher BP, highier risk of hemorrhagic stroke
after first 48hrs, BP goal gradually lowers to outpatient BP goal

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22
Q

Acute HTN treatment options

A

labetalol 10-20mg IV q10-20min (max 300mg)
nicardipine 5mg/hr IV titrated q5min to BP goal (max 15mghr)
sodium nitroprusside 0.5-10 mcg/kg/min IV titrated to BP goal (use if DBP > 140 mmHg)

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23
Q

HTN management after 48hrs

A

if BP still elevated, start PO meds if able to take: resume home antihypertensives, if no home therapy, start new

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24
Q

HTN management summary

A

utilize antihypertensives if above BP goal to minimize risk for hemorrhagic stroke: goal BP < 180/105 mmHg if tPA given, goal BP < 220/110 mmHg if no tPA
after 48hrs if patient hypertensive, gradually reduce to outpatient goal trhough (re)initiation of oral antihypertensives

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25
Q

Acute ischemic stroke management: thrombolytics

A

tissue plasminogen activator (tPA) - alteplase and tenecteplase
activate plasminogen –> converts plasmin –> lyses clot

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26
Q

Which type of stroke would you use a thrombolytic?

A

ischemic: atherosclerotic and cardioembolic

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27
Q

Thrombolytics utility

A

improves functional capabilities after an ischemic stroke (any ischemic stroke - cardioembolic, atherosclerotic)
NO impact on mortality, but can improve neurologic fx
ONLY in pts meeting eligibility criteria!!

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28
Q

tPA eligibility

A

must meet ALL inclusion and NO exclusion criteria
inclusion: diagnosis of ischemic stroke confirmed by imaging, sx onset </= 4.5 hours, age >/= 18yrs
exclusion: BP > 185/110 at time of adminsitration, BG < 50 mg/dL, anything that increases risk of bleeding

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29
Q

tPA agent - alteplase

A

0.9mg/kg IV (max 90mg)
10% given as bolus over 1 min: 0.09mg/kg
90% remaining infused over 60 min: 0.81mg/kg

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30
Q

tPA agents - tenecteplase

A

0.25mg/kg IV (max 25mg)
all given as IV bolus

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31
Q

tPA agents SEs

A

bleeding (including potentially causing hemorrhagic stroke) - keep BP < 180/105 mmHg to reduce risk of bleeding/hemorrhagic stroke and avoid ALL antiplatelets and anticoagulants for 24hrs after
cerebral edema

32
Q

Thrombolytic summary

A

pt must meet inclusion with NO exclusion criteria
dosing - be aware of max dose!
if administered, monitor for s/sx of bleeding, maintain BP goal, and avoid anticoagulants/antiplatelets for 24hrs

33
Q

Acute ischemic stroke management - antiplatelets

A

decrease in activation of P2Y12; COX enzyme inhibition
help decrease activation/aggregation of platelets

34
Q

Antiplatelet options for acute ischemic stroke management

A

aspirin monotherapy
aspirin + clopidogrel
ticagrelor
aspirin + ticagrelor

35
Q

Aspirin

A

MOA: irreversible inhibitor of COX enzyme, reducing formation of thromboxane A2, thus reducing platelet aggregation
for 1st line acute management of ischemic stroke
monitor: bleeding, stroke

36
Q

Who gets aspirin for a stroke?

A

ALL ischemic stroke pts initially, unless contraindicated: includes both embolic and atherosclerotic ischemic strokes
contraindications: active bleeding or high bleeding risk
>/= 24hrs if tPA administered (immediately if no tPA)

37
Q

Aspirin + clopidogrel

A

MOA: clopidogrel is a P2Y12 inhibitor which inhibits platelet aggregation through blockade of the ADP receptor
combo ONLY in minor strokes (NIHSS </=4)
aspirin 81mg daily + clopidogrel 75 mg daily
monitor: bleeding, stroke
second line

38
Q

Ticagrelor

A

MOA: P2Y12 inhibitor which inhibits platelet aggregation through blockade of the ADP receptor
ONLY in minor strokes (NIHSS </=5); can be used alone or in combo
180 mg once followed by 90 mg BID
monitor: bleeding, stroke
second line - likely used for true aspirin allergy

39
Q

Therapeutic anticoagulants

A

lack of research of therapeutic anticoagulants in the acute management of an ischemic stroke: no improvement in neurological fx or prevention of early recurrent stroke and increased bleeding - use aspirin instead to minimize risk of recurrent stroke acutely

40
Q

What if a pt comes in on an anticoagulant?

A

d/c anticoagulant and transition to aspirin
will NOT use tPA if on anticoagulant
if cardioembolic ischemic stroke or other indication for anticoagulant, recommended to start >/= 2-14 days after stroke

41
Q

Acute ischemic stroke summary

A

evaluate appropriateness of tPA
BP and glycemic control help minimize complications post-stroke
BP goal differs based on administration of tPA or not
antiplatelets recommended in acute management to prevent early recurrent ischemic stroke
monitor BP, s/sx of bleeding, stroke

42
Q

Hemorrhagic stroke overview

A

distinguishing sx: severe HA; usually more present compared to ischemic stroke
worse prognosis - increased mortality and worse functional outcomes
goal is to prevent re-bleeding/worsening of bleed

43
Q

For a subarachnoid hemorrhage use

A

nimodipine for vasospasms

44
Q

Acute managment overview

A

supportive care, glycemic control, reversing causative meds, surgery, antihypertensives, prevention of cerebral vasospasm, anticonvulsants

45
Q

Reversing causative medications

A

warfarin: IV vitamin K
heparin products: protamine
DOACs: dagitaran - idarucizumab (praxabind); other DOACs - recombinant coagulation factor Xa (andexxa)
antiplatelets: no antidote
holding agents, then giving reversals

46
Q

Surgery

A

craniotomy
endoscopic coiling or surgical clipping
endoscopic evacuation

47
Q

Antihypertensives - acute hemorrhagic stroke

A

to prevent acute rebleeding by controlling BP
treat if SBP > 180mmHg with IV antihypertensives
goal BP in 1st 24 hours < 180/110 mmHg
goal BP in hospital after 24 hours < 160/90 mmHg
after 48 hours, transtition to outpatient goal BP (<130/80)

48
Q

Prevention of vasospasm in hemorrhagic stroke

A

after subarachnoid hemorrhagic stroke, pts at risk for cerebral vasospasm which can worsen ischemia - highest risk 4-21 days after subarachnoid hemorrhagic stroke, worsens complications after a stroke
nimodipine (DHP CCB) used to minimize complications from cerebral vasospasm after a subarachnoid hemorrhage: 60 mg orally q4h for 21 days after hemorrhage

49
Q

Anticonvulsants

A

risk of seizure after hemorrhagic stroke
prophylactic anticonvulsants NOT recommended
only use if pt has a documented seizure history

50
Q

Acute hemorrhagic stroke summary

A

if stroke due to reversible cause, use antidote or reversal agents if available
BP control vital, nimodipine reduces complications from cerebral vasospasm if subarachnoid hemorrhage
most management is supportive care

51
Q

Secondary stroke prevention: antiplatelets vs anticoagulants

A

ischemic stroke pts will need an anticoagulant (more for cardioembolic) or antiplatelet (more for atherosclerotic) to prevent future strokes

52
Q

Secondary stroke prevention: antiplatelets

A

goal: prevent future strokes through the inhibition of platelet activation/aggregation
duration: indefinite until bleeding risk/complications outweigh the benefits of the meds

53
Q

Secondary stroke prevention: aspirin

A

first line treatment for secondary stroke prevention in atherosclerotic stroke
first 2-4wks: 162-325mg PO daily
after 2-4wks: </= 162 mg/day indefinitely (less bleeding compared to high dose)
SE/monitoring: bleeding, nausea

54
Q

Secondary stroke prevention: dipyridamole/aspirin

A

co-formulated capsule of dipyridamole 200mg/aspirin 25mg BID
MOA: dipyridamole inhibits adenosine phosphodiesterase thus preventing platelet aggregation
1st line treatment for secondary stroke prevention in atherosclerotic ischemic stroke
use this after transitioning off of high dose aspirin after the initial 2-4wks
SE/monitoring: HA, GI bleed

55
Q

Secondary stroke prevention: clopidogrel

A

2nd line treatment for secondary stroke prevention in nonembolic ischemic stroke (due to atherosclerosis) - use in aspirin intolerant pts, mostly used in combo with aspirin
75mg PO daily
SE/monitoring: bleeding

56
Q

Secondary stroke prevention: clopidogrel + aspirin

A

secondary stroke prevention for atherosclerotic ischemic stroke
minor strokes (NIHSS </=3): 1st line tx
moderate-severe strokes: 2nd line
clopidogrel 75 mg PO daily + aspirin 81 mg PO daily for 21-90 days then monotherapy
SE: bleeding

57
Q

Other antiplatelets in secondary prevention

A

ticagrelor + aspirin: decreased ischemic strokes, no difference in overall disability and increased bleeding with combo compared to aspirin
prasugrel: increased CV events and mortality (DON’T USE)
neither is recommended for secondary stroke prevention!

58
Q

Antiplatelets indication in secondary prevention

A

prevention of secondary strokes in pts with history of atherosclerotic ischemic stroke - recommended in all pts unless high bleeding risk or indications for other anticoagulants/antiplatelets
1st line: aspirin, dipyridamole/aspirin, clopidogrel + aspirin (NIHSS </=3)
2nd line: clopidogrel
contraindicated: prasugrel

59
Q

Secondary stroke prevention: anticoagulants

A

for cardioembolic stroke pts caused by atrial fibrillation, valvular heart disease, or severe heart failure : initiate >/=2-14 days after stroke; immediately after stroke, use aspirin instead of anticoagulant as lower bleeding risk; once starting anticoagulant, d/c aspirin (unless indicated)

60
Q

Secondary stroke prevention in atrial fibrillation: meds

A

apixaban, dabigatran, edoxaban, rivaroxaban, warfarin
if mechanical mitral valve/LV thrombus: warfarin/rivaroxaban

61
Q

Antiplatelet vs anticoagulant summary

A

used to prevent future occlusion of brain vasculature to minimize risk of future strokes: only use if ischemic!, NOT hemorrhagic

62
Q

Antiplatelet vs anticoagulant: when to use?

A

cardioembolic (afib, valvular disease, LV thrombus) = anticoagulant
atherosclerotic/thrombotic = antiplatelet
NOT in combo unless other indications

63
Q

Secondary stroke prevention: hypertension management

A

long-term goal BP < 130/80 mmHg for all pts with a h/o of stroke per stroke guidelines
conflicting results as to best antihypertensive therapy: one trial in stroke showed benefit of ACEis + thiazides; select therapies based on co-morbidities

64
Q

Antihypertensive selection: black

A

CCB, thiazide

65
Q

Antihypertensive selection: CKD

A

ACEi, ARB

66
Q

Antihypertensive selection: CAD

A

BB + ACEi (or ARB)

67
Q

Antihypertensive selection: diabetes

A

ACEi or ARB

68
Q

Antihypertensive selection: HF

A

neprilysin inhibitor/ARB, ACEi, or ARB + BB + aldosterone antagonist

69
Q

Antihypertensive selection: atrial fibrillation

A

BB or non-DHP CCB i.e diltiazem or verapamil

70
Q

Secondary stroke prevention: dyslipidemia

A

after an atherosclerotic ischemic stroke, all pts should be initiated on a high-intensity statin!: atorvastatin 80 mg daily or rosuvastatin 20-40 mg daily
LDL goal < 70 mg/dL: use ezetimibe and PCSK9 inhibitor if unable to reach goal on statin monotherapy
DO NOT use a statin if cardioembolic stroke or hemorrhagic stroke

71
Q

Additional risk factor reduction

A

reduce risk of future strokes through: cessation of illicit drugs (cocaine), reduction in alcohol consumption, diabetes control A1c<7%, physical activity (>/= 150 min/week), diet (mediterranean, low-salt), weight loss, smoking cessation

72
Q

Depression after stroke

A

occurs 25-50% of pts after an acute stroke
worsens recovery and linked to increased mortality

73
Q

Antidepressants

A

improve neurological functioning after a stroke
recommended antidepressants: SSRIs - sertraline, fluoxetine, escitalopram, citalopram
AVOID: paroxetine (more anticholinergic SEs), tricyclic antidepressants (anticholinergic SEs, arrhythmias)
start low and titrate up; duration unclear

74
Q

Rehabilitation

A

due to functional changes after a stroke, pts face many challenges including recovering activities of daily living
many require therapy at a rehab center to facilitate recovery and reconditioning after a stroke: speech therapy (swallowing, speaking), occupational therapy, physical therapy

75
Q

Ischemic stroke summary

A

acute management is similar b/w ischemic types (cardioembolic, atherosclerotic)
for secondary stroke prevention, differentiate cause of stroke to determine appropriate therapy to minimize risk of future strokes

76
Q

Hemorrhagic stroke summary

A

mose treatment is supportive and surgical
prevent future hemorrhagic strokes wtih: HTN and co-morbidity management, lifestyle modifications, evaluating need for therapies which can increase bleeding risk

77
Q

Stroke Management summary

A

acute management (inpatient): control BP, consider tPA if ischemic stroke and meets criteria, initiate antiplatelet therapy for ischemic stroke
chronic management (outpatient): initiate therapies to reduce risk of future strokes, monitor and manage other risk factors

PHRM 864 Module 4 (7 decks)

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