Stroke Flashcards
stroke definition
acute focal injury due to lack of blood/oxygen
types of stroke
atherosclerotic ischemic stroke
cardioembolic ischemic stroke
hemorragic stroke
what is an athersclerotic ischemic stroke
plaque buildup
what is a cardioembolic ischemic stroke
embolus likely due to afib
what is a hemorrhagic stroke
bleeding in brain from rupture to cerberal artery
stroke risk factors non-modifiable
age
FH
female
race
low birth weight
sickle cell disease
disease states at risk for stroke
CV dx
diabetes
HLD
HTN
lifestyle risk factors
illicit drug/alcohol use
obesity
cigarette smoking
clinical presentation of stroke
difficulty speaking
facial droop
weakness
ataxia
vision changes
headache
what imagine do we get in a stroke?
heat CT or MRI
what vital signs do we get stroke
oxygen sat
BP
what labs do we measure in stroke
CBC
BMP
glucose
INR, aPTT
why might we check blood sugar in a patient presenting with stroke symptoms?
they might have hypoglycemia, if so we should give quick sugar (carbs)
what tests do we do when testing for stroke
ECG
if ECG shows afib what kind of stroke is it likely
cardioembolic
if ECG normal and its ischemic what stroke likely
athersclerotic
blood clot would be which stroke
cardioembolic
thrombosis or plaque would be what stroke
athersclerotic
at what BG should we give insulin?
> 180 mg/dL
if not treated, worse mortality
argument for reducing blood pressure
minimize neurologic effects
decrease risk cereberal edema
prevent early stroke
argument for not reducing blood pressure
dropping too quickly can limit brain perfusion which can worsen ischemia and neurological function
when to check BP stroke
q15 min x 2 hours
q30 min x 6 hours
q1 hour x 16 hours
BP goals within first 48 hours
no tPA: < 220/110 mmHg
tPA: <180/105 mmHg
options to lower BP in stroke
labetalol
nicardipine
sodium nitroprusside
all IV drips
HTN management after 48 hours
start PO meds if possible
resume home anti-hypertensives
tPA agents
alteplase
tenecteplase
which type of stroke do we not use tPA?
hemorrhagic
does tPA improve mortality?
no, only helps improve neurologic function
inclusion criteria for tPA
ischemic stroke diagnosis confirmed by imaging (head CT)
symptom onset <= 4.5 hours
18+ years
exclusion criteria for tPA
bleeding
taking anticoag
BP > 185/110
BG < 50 mg/dL
alteplase dosing
0.9 mg/kg IV
max 90 mg
tenecteplase dosing
0.25 mg/kg
max: 25 mg
what to do with antocoags after tPA
hold all anticoag and antiplatelet for 24 hours after
what to monitor after tPA admin
BP < 180/105
signs/sx bleeding
hold all anticoag
antiplatelet options in ischemic stroke
ASA
ASA + clopidogrel
ticagrelor
ASA + ticagrelor
first line antiplatelet for ischemic stroke
high dose ASA for 2-4 weeks
who gets ASA?
all ischemic pts
no bleeding
> 24 hour after tPA or immediately if no tPA
ASA + clopidogrel used whne
second line for MINOR strokes
ticagrelor used when
second line only in MINOR strokes
if TRUE ASA allergy
do we use anticoags in ischemic?
no, increased risk bleeding
can start 2-14 days after stroke
what if a pt comes in on an anticoag with ischemic stroke?
d/c anticoag and switch to ASA
no tPA
what kind of stroke has worst prognosis
hemorrhagic
hemorrhagic stroke key symptom
headache
if warfarin caused hemorrhagic stroke what do we give
Vitamin K
if heparain caused hemorrhagic stroke what do we give
protamine
if dabigatran cause hemmorrhagic stroke what do we give
idarucizumab
if DOAC caused hemorrhagic stroke what do we give
andexxanant alpha
if antiplatelet cause hemorrhagic stroke what do we give
no reversal agent
when do we treat BP in hemorrhagic strok
SBP > 180
goal BP goal for hemorrhagic in first 24 hours
< 180/110
goal BP in hospital after 24 hours for hemorrhagic
<160/90 mm Hg
when are patients at risk for vasospasm
subarachoid hemorrhagic stroke
4-21 days after stroke
what drug can we give to minimize risk of vasospasm and when?
nimodipine in subarachnoid hemorrhage
60 mg every 4 hours for 21 days
do we prophylax for seizures?
no
can continue meds if they have them or if they have hx of stroke
what antiplatelet used in secondary prevention with atherosclerotic first line
first 2-4 weeks: high dose ASA
after 2-4 weeks: low dose ASA, ASA/dipyridamole, clopidogrel + ASA in minor
dipyridamole/aspirin consideration
need to titrate up
headache common, need titration to prevent
second line secondary stroke prevention antiplatelt in atherosclerotic
clopidogrel +/- ASA (more for minor strokes)
ASA intolerant pts
which antiplatelet contraindicated in secondary stroke prevention?
prasugrel
ticagrelor not really reccommended
when are anticoags reccommended as secondary prevention
ischemic cardioembolic stroke caused by afib, valvular disease, or heart failure
when are anticoags given in secondary prevention
2-14 days after stroke
discontinue ASA
DOACs used for who
cardioembolic pts except mitral valve or LV thrombus
who should use warfarin or rivaroxaban
mitral valve or LV thrombus
long term BP goal for all stroke pts
<130/80 mmHg
black preferred antihypertensive
CCB
thiazide
CKD preferred antihypertensive
ACE/ARB
CAD preferred antihypertensive
ACE/ARB + BB
diabetes preferred HTN agent
ACE/ARB
HF preferred HTN agent
BB + ACE/ARB/ARNI + spironolactone
Afib preferred anti-hypertensive
verapamil/dilt (non-DHP CCB) or BB
who should get statin
atherosclerotic stroke
high intensity statin
LDL goal for atherosclerotic stroke
<70
who should not get statin
cardioembolic stroke
hemorrhagic stroke
(unless already on )
risk factor reduction items
stop ilicit drugs
decrease alcohol
diabetes a1c < 7
physical activity
diet
weight loss
smoking cessatio
reccommended antidepressants
sertraline, fluoxetine, escitalopram, citalopram
antidepressants to avoid
paroxetine
TCAs
