Stroke Flashcards
Defining Stroke Types
Ischemic: an ___ of brain tissue resulting from compromised blood flow
- ___ ischemic stroke
- ___ ischemic stroke
___ : bleeding in the brain due to rupture of a cerebral artery
- Also called an intracranial hemorrhage (ICH)
- infarction
- atherosclerotic
- cardioembolic
- hemorrhagic
Pathophysiology of Atherosclerotic Stroke
___ plaque buildup and blood clot blocks artery
cholesterol
Pathophysiology of Cardioembolic Stroke
___ leads to clot, clot goes to brain and blocks blood flow
AFib
Pathophysiology of Hemorrhagic Stroke
___ in cerebral artery breaks open, causing brain bleed
- ___ of blood on brain causes brain tissue death
Aneurysm
pressure
Stroke Risk Factors
Non-modifiable
- Age
- Family history
- Gender ( ___ )
- Race
- Low birth weight
- ___ cell disease
Modifiable
Disease states
- Cardiovascular diseases (atrial
fibrillation, valvular diseases)
- Diabetes
- Hyperlipidemia
- Hypertension
Lifestyle
- Illicit drug/alcohol abuse
- Obesity/physical inactivity
- Cigarette smoking
- Females
- sickle
Clinical Presentation
- ___ (difficulty speaking)
- ___ droop
- Unilateral or bilateral weakness
- ___ (inability to coordinate muscle movement)
- ___ changes (diplopia)
- Headache (more common with ___ )
- dysphasia
- facial
- ataxia
- vision
- hemorrhagic
Assessment
Imaging
- Head CT or MRI
Vital Signs
- ___
- ___ saturation
Labs
- Blood ___
- BMP
- CBC
- Hematologic markers: ___ , aPTT
If ischemic stroke with atrial fibrillation or valvular abnormalities, usually ___ . If ischemic stroke with normal sinus rhythm, usually ___
Tests
- ___
- Echocardiogram
- BP
- O2
- BG
- cardioembolic
- atheroscleotic
- ECG
Acute Ischemic Stroke Management
Hypoglycemia
- Can cause ___ changes mimicking a stroke
- Treat with carbohydrates to maintain euglycemia
Hyperglycemia
- In the setting of an acute stroke, elevated BG (> ___ mg/dL) has
resulted in worse morbidity and mortality
- Treat with ___ insulin to maintain BG < ___ mg/dL while inpatient (only use an insulin drip if patient in acidosis)
- neurological
- 180
- SC, 180
Medication Access
Due to physiologic changes after a stroke, patients must be evaluated for their ability to ___
- if NPO, utilize alternative for administration of meds/nutrition
swallow
Acute Blood Pressure Management
Argument for reducing blood pressure
- Minimize ___ neurological deficits
- Decrease risk of cerebral ___ and hemorrhagic transformation
- Prevention of early ___ stroke
Argument against reducing blood pressure (“permissive hypertension”)
- Dropping blood pressure too quickly can limit brain ___ which can
worsen ischemia and neurologic function
Blood pressure control after a stroke requires a ___ !
- long term
- edema
- recurrent
- perfusion
- balance
Acute Blood Pressure Goals
Check BP Q15min x 2H, then Q30min x 6H, then Q1H for 16H
BP goals within first 48 hours – higher than normal BP goals to allow permissive HTN
- No tPA: < ___ / ___ mmHg
- tPA administered: < ___ / ___ mmHg
After first 48 hours, BP goal gradually lowers to outpatient BP goal
- 220/110
- 180/105
Acute Hypertension Treatment Options
- ___ 10-20 mg IV q10-20 min (max 300 mg)
- ___ 5 mg/hr IV titrated q5min to BP goal (max 15 mg/hr)
- ___ 0.5-10 mCg/kg/min IV titrated to BP goal (use if DBP > ___ mmHg)
- labetalol
- nicardipine
- sodium nitroprusside, 140
Hypertension Management After 48H
If BP elevated after __ hours, start PO medications if able to take
- Resume home antihypertensives (if applicable)
- if no home therapy, select therapy based on co-morbidities
48
Hypertension Management Summary
Utilize antihypertensives if above BP goal to minimize risk for hemorrhagic stroke
- Goal BP < ___ / ___ mmHg if tPA administered
- Goal BP < ___ / ___ mmHg if no tPA
After 48 hours, if patient hypertensive, gradually reduce to outpatient goal through (re)initiation of
oral antihypertensive(s)
- 180/105
- 220/110
Thrombolytics
Tissue plasminogen activator (tPA)
(2)
- alteplase
- tenecteplase
Thrombolytics
Utility
- Improves functional capabilities after an ___ stroke (any ischemic stroke: cardioembolic, atherosclerotic, etc.)
- NO impact on mortality, but can improve ___ function
- ONLY IN PATIENTS MEETING ELIGIBILITY CRITERIA
- ischemic
- neurologic
tPA Eligibility
Must meet ALL inclusion and NO exclusion criteria
inclusion:
- ___ stroke
- Symptom onset < ___ hours
- Age > 18 years
exclusion:
- not bleeding
- BP > ___ / ___ at time of administration
- BG < ___ mg/dL
- ischemic
- 4.5
- 185/110
- 50
tPA Agents
Alteplase: 0.9 mg/kg IV (max ___ mg) - round to nearest tenth
- 10% (0.09 mg/kg) given as bolus over 1 minute
- 90% (0.81 mg/kg) remaining infused over 60 minutes
Tenecteplase: 0.25 mg/kg IV (max ___ mg) – round to nearest integer
- All given as IV bolus (used off-label)
Side effects
- ___ (including potentially causing a ___ stroke)
- Keep BP < ___ / ___ mmHg to reduce risk of bleeding/hemorrhagic stroke
- Avoid ALL antiplatelets and anticoagulants for 24 hours after
- Cerebral edema
- 90
- 25
- bleeding, hemorrhagic
- 180/105
antiplatelets
Options for acute ischemic stroke management
- Aspirin monotherapy
- Aspirin + clopidogrel
- Ticagrelor
- Aspirin + ticagrelor
Aspirin
Mechanism of action:
- ___ inhibitor of COX enzyme, reducing the formation of thromboxane A2, thus reducing platelet aggregation
Utility:
- First-line for acute management of ___ stroke
- Studies show a ___ in early recurrent ischemic stroke with high dose
aspirin (160-325 mg daily) for __ - __ weeks
Monitoring: ___ , stroke
- irreversible
- ischemic
- decrease, 2-4
- bleeding
Aspirin
Who gets aspirin for a stroke?
- All ___ stroke patients initially unless contraindicated
- Includes both embolic and atherosclerotic ischemic strokes
- Contraindications include active ___ or high bleeding risk
- > 24 hours if ___ administered (immediately if no tPA)
- ischemic
- bleeding
- tPA
Aspirin + Clopidogrel
Mechanism of action: clopidogrel is a ___ inhibitor which inhibits
platelet aggregation through blockade of the adenosine diphosphate (ADP)
receptor
Dosing: Data of combo ONLY in ___ strokes (NIHSS < 4)
- CHANCE: combination of aspirin 81 mg PO daily + clopidogrel 75 mg PO daily x 3 weeks decreased __ stroke
- POINT: combination of aspirin 81 mg PO daily + clopidogrel 75 mg PO daily x 90 days decreased ___ stroke but increased major ___
Monitoring: ___ , stroke
Utility: combo aspirin/clopidogrel second line recommendation for ___
strokes
- P2Y12
- minor
- minor
- minor
- bleeding
- bleeding
- minor
Ticagrelor
Mechanism of action: ticagrelor is a ___ inhibitor which inhibits platelet aggregation through blockade of the adenosine diphosphate (ADP) receptor
Data ONLY in ___ strokes (NIHSS < 5)
- SOCRATES: ticagrelor vs. aspirin x 90 days - Not superior with similar safety
- THALES: ticagrelor + aspirin x 30 days vs. aspirin alone decreased ___ stroke compared to aspirin, but no difference in overall disability and increased bleeding risk
Dosing: 180 mg PO once followed by 90 mg PO BID
- P2Y12
- minor
- recurrent
Ticagrelor
Monitoring: bleeding, stroke
- Utility: likely ___ line due to safety concerns (alone or in combination)
- Likely use for true ___ allergy
- 2nd
- ASA
Therapeutic Anticoagulants
Lack of research of ___ anticoagulants in the acute management of an ___ stroke
- No improvement in neurological function or prevention of early
recurrent stroke and ___ bleeding
- Use aspirin instead to minimize risk of recurrent stroke acutely
What to do if came in on anticoagulant?
- Discontinue anticoagulant and transition to ___
- Will not use ___ if on anticoagulant
- If ___ ischemic stroke or other indication for anticoagulant, recommended to start > __ - __ days after stroke
- therapeutic, ischemic
- increased
- ASA
- tPA
- cardioembolic, 2-14
Acute Ischemic Stroke Summary
Evaluate appropriateness of tPA
- ___ and ___ control help minimize
complications post-stroke
- BP goal differs based on administration of ___ or not
- Antiplatelets recommended in acute management to
prevent early ___ ischemic stroke
- Monitor blood pressure, signs/symptoms of bleeding, stroke
- BP, BG
- tPA
- recurrent
