stroke

Question 1

what is ischemic stroke

Answer 1

an infarction of brain tissue resulting from compromised blood flow

Question 2

Risk factors for stroke

Answer 2

Age
family history
gender
race
low birth weight
sickle cell disease
Cardiovascular disease, Afib, diabetes, hyperlipidemia, hypertension, drug use, obesity, alcohol use, cigarette use

Question 3

Clinical presentation of stroke

Answer 3

Dysphasia, facial droop, unilateral or bilateral weakness, ataxia, vision changes, headache

Question 4

Assessment

Answer 4

CT or MRI will tell us if it is an ischemic stroke or a hemorrhagic stroke

If it is a ischemic stroke we then need to do an ECG and if the ECG shows Afib it is cardioembolic and if ECG is normal then atherosclerotic

Question 5

Acute ischemic stroke management - Glycemic control

Answer 5

BP goal is <180mg/dL
If BP goes over 180 give subQ insulin

Question 6

Acute ischemic stroke management - Blood Pressure

Answer 6

Check BP Q15min x 2H then Q30min x 6H, then Q1H for 16H

in first 24 hours goals
tPA given : <180/105 mmHg
NO tPA: <220/110mmHg

After first 24-48 hours
<160/90

After that
<130/80 or <140/90

Question 7

Acute ischemic stroke management - blood pressure treatment

Answer 7

Labetalol IV
Nicardipine IV
Sodium nitroprusside IV

If BP is elevated after 48 hours start PO medications

Question 8

Acute ischemic stroke management - thrombolytics

Answer 8

ONLY in patients meeting elegibility criteria
Inclusion criteria: Diagnosed ischemic stroke, onset of symptoms less than or equal to 4.5 hours

Exclusion criteria: Anything that increases bleeding ( surgery, GI bleed, MI in the past 3 months), Blood pressure: >185/110, Blood glucose: <50

Question 9

Acute ischemic stroke management - Thrombolytics treatment

Answer 9

Alteplase: 0.9mg/kg IV (MAX 90mg) - give 10% over 1 minute and 90% over 60 minutes

Tenecteplase: 0.25mg/kg IV (max dosing 25mg)

IF PATIENT IS 100KG OR MORE ONLY USE MAX DOSING NO LONGER WEIGHT BASED

Keep blood pressure <180/105mmHg

Question 10

Acute ischemic stroke management - Antiplatelets treatment

Answer 10

Aspirin - First line high dose for 2-4 weeks
Aspirin + Clopidogrel - for minor stroke second line (baby aspirin dose and 75mg QD of clo)
Ticagrelor - Second line (use for true aspirin allergy)

Must give 24 hours after tPA if administered

Question 11

Acute Cardioembolic ischemic stroke management - Anticoagulants

Question 12

Acute Hemorrhagic ischemic stroke management - Hypertensive goal

Answer 12

Treat if SBP >180

Goal BP first 24Hrs <180/110 mmHg

Goal BP after 24hrs <160/90

after 48 hours <130/80 or <140/90

Question 13

Subarachnoid Hemorrhagic - prevention of vasospasm

Answer 13

Nimodipine 60mg orally Q4H for 21 days

Question 14

Secondary Stroke prevention for Atherosclerotic

Answer 14

After completing high dose aspiring for 2-4 weeks will do 81mg baby aspirin for the rest of their lives

Can also do Dipyridamole/aspirin as first line instead of ASA 81mg

Question 15

Secondary stroke prevention for cardioembolic stroke

Answer 15

patient will be put on aspirin for 2-14 days until anticoag treatment is recommended and then will start a DOAC unless they have mechanical mitral valve/LV thrombus then use warfarin

Question 16

Secondary stroke prevention - Dyslipidemia Atherosclerotic

Answer 16

LDL goal <70

patient should be on high intensity statin
atorvastatin or rosuvastatin

Question 17

Additional risk reduction

Answer 17

Diet
stop illicit drug use
workout
reduce alcohol consuption
diabetes control (A1c <7%)
smoking cessation
weight loss

Question 18

Depression after stroke

Answer 18

Always counsel patients and if needed start SSRI

Question 19

outline Atheroslerotic

Answer 19

BG <180
BP with tPA : <180/105
BP without tPA: <220/110
Give aspirin high dose for 2-4 weeks
after 2-4 weeks give 81mg ASA indefinitely
Give high intensity statin with LDL goal of <70
Lifestyle changes
And evaluate for depression

Question 20

Outline Cardioembolic

Answer 20

BG <180
BP with tPA : <180/105
BP without tPA: <220/110
Give aspirin 325mg for 2-14 days then D/C and start DOAC unless Mechanical valve then give warfarin
Lifestyle changes and evaluate for depression

Question 21

Outline for hemorrhagic

Answer 21

BG< 180
BP 24hr <180/105
BP after 24hrs <160/90
BP after 48hrs <130/80 or <140/90
If due to medication use reversal agent
Statin
Evaluate for depression and consider lifestyle modifications

Question 22

Reversing causative medication - hemorrhagic stroke

Answer 22

Warfarin - IV vitamin K
Heparin products: Protamine
Dabigatran - idarucizumab
Other DOACs - Andexxa (Coagulantion factor Xa)
Antiplatelets: No antidote