Stroke Flashcards
abrupt development of a focal neurological deficit that occurs due to inadequate blood supply to an area of the brain, can be thrombotic or embolic
ischemic stroke
ischemic stroke that occurs when a thrombus forms inside an artery in the brain
thrombotic ischemic stroke
ischemic stroke that occurs when a piece of thrombus originating either inside or outside of the cerebral vessels breaks loose and is carried to the site of occlusion in the cerebral vessels
embolic ischemic stroke
a result of bleeding into the brain and other spaces within the central nervous system and includes subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and subdural hematomas
hemorrhagic stroke
a short episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction, have a rapid onset and short duration typically lasting less than an hour and often less than 30 minutes, no deficit remains after the attack
transient ischemic attack (TIA)
- Age (greater than 55)
- Gender (males greater than females at older ages)
- Race and ethnicity
- Genetic predisposition
- Low birth weight
- Hypertension (most important risk factor)
- Cardiac disease
- TIAs or prior stroke
- Diabetes
- Dyslipidemia
- Asymptomatic carotid stenosis
- Oral contraceptive use with higher estrogen content
- Postmenopausal hormone therapy
- Sickle cell disease
- Lifestyle factors like smoking, excessive alcohol use, physical inactivity, obesity, diet, cocaine and IV drug use, low socioeconomic status
ischemic stroke risk factors
- Hypertension
- Trauma
- Smoking
- Cocaine use
- Heavy alcohol use
- Anticoagulant use
- Cerebral aneurysm and AVM rupture
hemorrhagic stroke risk factors
when is aspirin NOT recommended for primary stroke prevention?
patients with diabetes, asymptomatic peripheral arterial disease, at low risk of stroke
most important initial diagnostic test in patients with suspected stroke because need to differentiate ischemic from hemorrhagic since treatment for each differs
brain CT or MRI scan
________ therapy must be avoided until hemorrhagic stroke is ruled out
fibrinolytic
weakness on one side of the body, facial droop, inability to speak, loss of vision, vertigo, headache, falling, hemiparesis (weakness or paralysis on one side of the body), monoparesis (weakness or paralysis of only one limb), hemisensory deficit (loss of sensation on one side of the body typically affecting the face/arm/leg), posterior circulation involvement in patients with vertigo and double vision, aphasia (affected ability to understand, produce, or use language) in patients with anterior circulation strokes, dysarthria (difficulty speaking), visual field defects, altered levels of consciousness
signs and symptoms of ischemic stroke
may be performed rapidly, have demonstrated utility, may be administered by a broad spectrum of healthcare providers with accuracy and reliability. Having a standardized scale quantifies the degree of neurological deficit, helps identify patients for fibrinolytic or mechanical intervention, objective measure of changing clinical status, identifies those at higher risk for complications
National Institutes of Health Stroke Scale (NIHSS) purpose in clinical practice
1A – level of consciousness
1B- orientation questions
1C – response to commands
2 – gaze
3 – visual fields
4 – facial movement
5 – motor function (arm)
6 – motor function (leg)
7 – limb ataxia (muscle coordination)
8 – sensory (sensory loss)
9 – language
10 – articulation
11 – extinction or inattention
NIHSS components
reducing secondary brain damage by re-establishing and maintaining adequate perfusion to marginally ischemic areas of the brain and protecting those areas from the effects of ischemia
short term treatment goals of ischemic stroke
prevention of a recurrent stroke through reduction and modification of risk factors and by use of appropriate treatments, prevention of long-term disability and death related to stroke
long-term treatment goals of ischemic stroke
why is hypertension NOT generally treated within the acute period of a stroke? when would antihypertensives be used?
it may cause decreased blood flow to the ischemic areas which may increase the infarction size. The use of antihypertensive agents may be necessary in patients with severely elevated BP who are otherwise candidates for fibrinolytic therapy, patients with stroke and other medical disorders like aortic aneurysm rupture, MI, heart failure.
antihypertensive agents for treatment in ischemic stroke if necessary
labetalol, nicardipine, clevidipine, if uncontrolled or diastolic greater than 140 mmHg then use nitroprusside
- 18 years of age or older
- Clinical diagnosis of ischemic stroke causing a measurable neurological deficit
- Time of symptom onset well established to be less than 4.5 hours before treatment would begin
inclusion criteria for use of alteplase in ischemic stroke
- Non-disabling mild stroke (NIHSS 0–5)
- Clinical presentation suggestive of SAH even with a normal head CT or intracranial hemorrhage on imaging
- Active internal bleeding
- Current oral anticoagulant use
- Current use of direct thrombin inhibitors or direct factor Xa inhibitors
- Previous intracranial hemorrhage
exclusion criteria for use of alteplase in ischemic stroke
IV alteplase time frame from onset of stroke symptoms, recommended dosing for ischemic stroke
should be give to patients who can be treated within 3 hours of ischemic stroke symptom onset or for selected patients who can be treated within 3-4.5 hours, 0.9mg/kg with max dose at 90mg
how is efficacy determined after treatment with alteplase?
elimination of existing neurological deficits and long-term improvement in neurological status and function
major adverse effects of fibrinolytic therapy
major bleeding and angioedema
CT scan should be done ____ hours after IV infusion of alteplase before initiating ______ or ________
24, anticoagulants, antiplatelet agents
time frame that aspirin should be given depending on if a patient received alteplase or not? dosing?
if treated with alteplase - delayed 24 hours later
if not treated with alteplase - within 24-48 hours after onset
dose is 160-300mg
What are recommendations (agent(s), timeframe, duration) for antiplatelet therapy in patients with a minor noncardioembolic ischemic stroke who did not receive alteplase?
dual antiplatelet therapy - aspirin 75 mg daily and clopidogrel initial dose 300 mg then 75 mg daily started within 24 hours after symptom onset and continued for 21 days
antiplatelet recommendations for secondary prevention of ischemic stroke
aspirin 50-325 mg as monotherapy, clopidogrel 75 mg, ER dipyridamole 200 mg plus aspirin 25 mg
when should anticoagulants be used for secondary prevention of ischemic stroke?
in patients with AF and a previous TIA or stroke
What additional conditions should be appropriately managed, and medications used for the secondary prevention of ischemic stroke?
hypertension, diabetes, lipids, cessation of smoking, increased physical activity, reducing alcohol use in heavy drinkers, statin therapy recommended in patients with previous stroke or TIA regardless of history of coronary artery disease
Sudden severe headache, nausea, vomiting, photophobia, “worst headache of my life”, neck pain and nuchal rigidity/stiffness (stiffness and pain in the neck)
signs/symptoms of hemorrhagic stroke
rapid neurointensive care to maintain adequate oxygenation, breathing, and circulation
short term treatment goals for hemorrhagic stroke
prevention of complications and of a recurrent bleed and delayed cerebral ischemia, prevention of long-term disability and death related to stroke
long term treatment goals for hemorrhagic stroke
why is BP management important for patients with hemorrhagic stroke, goal values and preferred agents?
prevent rebleeding and expansion of hematoma, systolic BP greater than 220 mmHg - BP lowering using continuous IV infusion recommended, can be controlled with IV boluses of labetalol 10-80 mg every 10 minutes to a maximum of 300mg or with IV infusions 0.5-2mg/min or nicardipine (5-15mg/hour)
What medication is recommended after a subarachnoid hemorrhage (SAH) to prevent delayed cerebral ischemia? What timeframe and dosing are recommended?
oral nimodipine, promptly after event but no later than 96 hours after SAH, 60 mg PO Q4H for 21 days
