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864 > Stroke > Flashcards

Stroke Flashcards

1
Q

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)

A
  • infarction
  • atherosclerotic
  • cardioembolic
  • hemorrhagic
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2
Q

Pathophysiology of Atherosclerotic Stroke

___ plaque buildup and blood clot blocks artery

A

cholesterol

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3
Q

Pathophysiology of Cardioembolic Stroke

___ leads to clot, clot goes to brain and blocks blood flow

A

AFib

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4
Q

Pathophysiology of Hemorrhagic Stroke

___ in cerebral artery breaks open, causing brain bleed
- ___ of blood on brain causes brain tissue death

A

Aneurysm
pressure

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5
Q

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

A
  • Females
  • sickle
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6
Q

Clinical Presentation

  • ___ (difficulty speaking)
  • ___ droop
  • Unilateral or bilateral weakness
  • ___ (inability to coordinate muscle movement)
  • ___ changes (diplopia)
  • Headache (more common with ___ )
A
  • dysphasia
  • facial
  • ataxia
  • vision
  • hemorrhagic
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7
Q

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

A
  • BP
  • O2
  • BG
  • cardioembolic
  • atheroscleotic
  • ECG
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8
Q

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)

A
  • neurological
  • 180
  • SC, 180
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9
Q

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

A

swallow

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10
Q

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 ___ !

A
  • long term
  • edema
  • recurrent
  • perfusion
  • balance
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11
Q

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

A
  • 220/110
  • 180/105
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12
Q

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)
A
  • labetalol
  • nicardipine
  • sodium nitroprusside, 140
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13
Q

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

A

48

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14
Q

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)

A
  • 180/105
  • 220/110
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15
Q

Thrombolytics

Tissue plasminogen activator (tPA)
(2)

A
  • alteplase
  • tenecteplase
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16
Q

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

A
  • ischemic
  • neurologic
17
Q

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

A
  • ischemic
  • 4.5
  • 185/110
  • 50
18
Q

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

A
  • 90
  • 25
  • bleeding, hemorrhagic
  • 180/105
19
Q

antiplatelets

Options for acute ischemic stroke management
- Aspirin monotherapy
- Aspirin + clopidogrel
- Ticagrelor
- Aspirin + ticagrelor

A
20
Q

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

A
  • irreversible
  • ischemic
  • decrease, 2-4
  • bleeding
21
Q

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)

A
  • ischemic
  • bleeding
  • tPA
22
Q

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

A
  • P2Y12
  • minor
  • minor
  • minor
  • bleeding
  • bleeding
  • minor
23
Q

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

A
  • P2Y12
  • minor
  • recurrent
24
Q

Ticagrelor

Monitoring: bleeding, stroke
- Utility: likely ___ line due to safety concerns (alone or in combination)
- Likely use for true ___ allergy

A
  • 2nd
  • ASA
25
Q

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

A
  • therapeutic, ischemic
  • increased
  • ASA
  • tPA
  • cardioembolic, 2-14
26
Q

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

A
  • BP, BG
  • tPA
  • recurrent

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