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CardioPulm II > Stroke > Flashcards

Stroke Flashcards

1
Q

Hemorrhagic Stroke: Clinical presentation

A

Worst headache of your life and decreased level of conscientious.

other details,
headache, dizziness, seizures, vomiting, neck rigidity

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2
Q

Hemorrhagic Stroke:
Intracerebral hemorrhage

Secondary Causes

A

uncontrolledbloodpressure ,antithrombotic or thrombolytic

agents

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3
Q

Hemorrhagic Stroke:

Subarachnoidhemorrhage (SAH)

A

A. Blood enters cerebrospinal fluid

B. Secondary to trauma, rupture of an intracranialaneurysm ,or rupture of an arteriovenous malformation (AVM)

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4
Q

Treatment:
SAH secondary to aneurysm rupture

Associated with increased incidence of delayed cerebral ischemia (DCI)

  • > Occurs between 4 and 21 days after bleed
  • ->Underlying cause of of DCI is vasospasm of cerebral vaculature
A

Nimodipine - used to reduce the compilation owing to DCI

60mg PO every 4 hours X 21 days

ADR: Hypotension

Reduce dosing interval to 30mg PO every 2h (same daily dose) or reduce total daily dose 30mg PO every 4th

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5
Q

Nimodipine (Nimotop): Black Box Warning

A

Do not administer intravenously or parenterally. Will cause Death and Serious ADR.

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6
Q

Secondary Prevention: Non-Cardioembolic TIA/Stroke

Artherothrombotic, lacunar, or cryptogenic

What drugs are available and what dose?

A

Aspirin 50-325 PO daily –Cheap *best

ASA 25 mg /Dipyridamole ER (Aggrenox) 200mg PO BID*ok

Clopidogrel 75mg PO daily *last

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7
Q

Secondary Prevention: Non-Cardioembolic TIA/Stroke

What’s better ASA or ASA/dipyridamole( Aggrenox)?

A

IR dipyridamole failed to show benefit over ASA
-> due to its short half-life and reduced absorption

Aggrenox: HA in 40% of pts. Titrated the does: take 1 pill at night for 2wks, then BID.

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8
Q

Secondary Prevention: Non-Cardioembolic Stroke/TIA

What about long term, Dual anti-playlet therapy?

A

Combo of ASA and Clopidegrel–> is not recommneed

BUT** DAPT is indicated if history of ACS/PCI –> look for stent or intracranial stenosis.

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9
Q

Secondary Prevention: Cardioembolic Stroke

Use CHADs VASc:

Anticoagulation:

A 
C - Congestive HF
H - HTN
A2 - age >75 (2 points)
D - DM
S2 - PMH of Stroke (opts)
V - vascular disease
A - age 65-74
Sc - sex category ( Female)

0= Choose nothing
1= Choose nothing or ASA or anticoagulation
≥2= Anticoagulation

o No treatment = 0
o ASA 81 -325 mg po daily (usually 81 mg) 
 - Warfarin Goal INR 2-3 --DOC
o Dabigatran 150 mg PO BID
o Rivaroxaban 20 mg PO daily with a mea
o Apixaban 5 mg PO BID
o Edoxaban 60 mg PO Daily
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10
Q

Primary and Secondary Prevention of Stroke

Hypertension

Drugs and Goals?

A

ACEI + Thiazide or ARB

Goal

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11
Q

Primary and Secondary Prevention of Stroke

Lipid Management: SPARCL (ATV 80 vs. PLB)

Drugs, situation, and goals

A

ATV 40-80 mg daily and ROSVA 20-40 mg daily

Stroke only from artherosclorisis.

Decrease in LDL of at least 50% from baseline

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12
Q

Primary and Secondary Prevention of Stroke

Diabetes mellitus with risk or history of CVD

A

Secondary: ASA 75-162 mg hx of CVD

and

Primary: Aspirin tx (75–162 mg/day) in (1) DM with 10-year risk>10%.

(2) Men 50 yrs of age or women 60 yrs of age who have at least one of the following factors:
(family hx of CVD, HTN, smoking, dyslipidemia, or albuminuria).

Goal Ha1C

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13
Q

Primary and Secondary Prevention of Stroke

Antiplatelet Treatment – Primary Prevention

A

PRIMARY: ASA low dose 81 mg

Men ages 45-79 and Women 55-79

For women the major benefit is stroke prevention

men the primary major benefit is MI prevention

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14
Q

Primary and Secondary Prevention of Stroke:

Obesity/Ethanol Use

Weight management program

Exercise program Healthy diet with increased fruits/ vegetables

Limit alcohol intake

A

Obesity
Goal body mass index 18.5- 24.9 kg/m2

Ethanol
≤ 2 drinks (males)
≤ 1 drink (non-pregnant females)

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15
Q

Primary and Secondary Prevention of Stroke:

Tobacco

A

Bupropion

Nicotine patch/ gum

Varenicline

Nonpharmacologic management`

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16
Q

Acute Ischemic Stroke – Treatment

General Treatment Principles

A
  1. To identify candidates for thrombolytics within 4.5 hours**
  2. Close monitoring of patient for change in metal status
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17
Q

General Treatment Interventions for Acute Ischemic Stroke

A

Fluid management: Dehydration and Hypotension

Hyperglycemia: maintain range of 140-180 mg/dL

Hypoglycemia: (38C

Hypertension : mentioned later

DVT/PE prevention: “”

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18
Q

Pharmacologic Treatment of Acute Stroke

Drug/Amistration/BP/other drug??

A

(r-tPA) alteplase- (Activase® )

• Half life 3-8 minutes

  1. Dose: 0.9mg/kg (maximum 90mg)
  2. the first 10% given IV bolus
  3. remaining 90% given by continuous infusion over 1 hour.
  4. BP
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19
Q

(r-tPA) alteplase- (Activase® )

ADR and Precautions

A

Bleeding, angioedema (tx with ranitidine, diphenhydramine, methylprednisolon)

Develops headache, acute HTN, N/V has worsening neurological exam,
–>discontinue the infusion and obtain emergent CT scan

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20
Q

(r-tPA) alteplase- (Activase® )

Monitoring

A 
Monitoring Parameters: 
BP, Neurologic function, bleeding:
1.q15min X 2hrs
2. Then q30min x 6 hrs
3. Then q60min x 24 hrs
4. qshift
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21
Q

NINDS r-tPA Stroke Study Group study:

Excustion Critieria

A
  1. History of previous intracranial hemorrhage
  2. Elevated blood pressure > 185/110
  3. Platelet count 1.7 or PT >15 seconds
  4. Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays
  5. Blood glucose concentration
22
Q

NINDS r-tPA Stroke Study Group study:

Inclusion Critieria

A
  1. Treatment within 45 minutes
  2. age > 18
  3. ishemic stroke with measurable neuralgic deficit
23
Q

NINDS r-tPA Stroke Study Group study: (3 hour window)

Relative excision criteria

A
  1. minor or rapidly improving stroke symptoms
  2. Pregnacy
  3. MI within 3 months
  4. any trauma or surgery within 14 days
  5. UTI or GI hemorrhage within 21 days
24
Q

ECASS Study:

Additional exclusion criteria if within 3-4.5 hours of onset.

A

! Patient > 80 years
! Those taking oral anticoagulant regardless of their INR
! Baseline NIHSS score > 25
! Those with hx of stroke and diabetes

25
Q

ECASS Study: Expansion of the Time Window for Tx of Acute Ischemic Stroke with r-tPA

A

patients to test the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke

AHA/ASA recommends r-tPA to be given to eligible patients who can be treated in the time period of 3-4.5 hours after stroke

26
Q

NINDS r-tPA Stroke Study Group study:

A

When inclusion and exclusion of giving rtPA not followed there is increased risk of hemorrhage 15.7 % - 3X rate in other studies

The bottom -Stick with the guidelines for giving r-tPA

27
Q

Acute Ischemic Stroke: Antiplatelet agents

Aspirin

A

• 325 mg within 48 hours after stroke onset

Wait 24 hours if tPA was used

28
Q

Acute Ischemic Stroke: Antiplatelet agents

DAPT

A

The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 90 days

If the patient ends up receiving rtPA, then aspirin 325mg or DAPT can be given after 24 hours

29
Q

Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH

A
  • Has NOT been shown to decrease disability or mortality

* Has NOT been shown to decrease risk of recurrent stroke • # risk for systemic and CNS hemorrhage

30
Q

Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH:

AFib

A

Do not use anticoagulation for stroke or A.Fib (UFH/LMWH)

For most patients with a stroke or TIA in the setting of AF, it is reasonable to initiate ORAL anticoagulation within 14 days after the onset of neurological symptoms

31
Q

Acute Ischemic Stroke: antithrombotic tx for prevention of DVT/PE

A

Low dose UFH/LMWH should be restricted for 24 hours after administration of thrombolytic therapy.

low dose has less risk of intracrannial hemorrhage

32
Q

Blood Pressure Management in Acute Stroke

A

Used to achieve 185/110 so tPA can be used

if not using tPA:

Use if BP > 220/120

or

When patient has the following medical conditions:

  • Evidence of aortic dissection
  • Acute myocardial infarction
  • Pulmonary edema
  • Hypertensive encephalopathy

Goal: reduce systolic BP by 15% during the 1st 24 hrs after stroke onset

33
Q

Blood Pressure Management in Acute Stroke

Agents :Indication that patient is eligible for treatment with intravenous rtPA

SBP >185mmHg or DBP>110mmHg

A

Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat once

or

Nicardipine infusion  (dihyropyridine CCB)
5 mg/h, titrate up by 2.5 mg/h, , maximum dose 15 mg/h; when desired blood
pressure reached.

and

If BP is not maintained at or below 185/110 mmHg, do NOT administer rtPA

34
Q

Labetalol ADR

A

Labetalol: Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension

35
Q

Nicardipine ADR

A

Nicardipine: Tachycardia, headache, flushing, local phlebitis

36
Q

Nitroprusside ADR

A

Nitroprusside: Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication

37
Q

Blood Pressure Management in Acute Stroke

Management of blood pressure during and after treatment with rtPA or other acute reperfusion intervention – maintain BP at or below 180/105 mmH

SBP between 180-230 mmHg or
DBP between 105-120 mmHg

A

Labetalol 10 mg IV followed by an continuous infusion at 2 to 8 mg/min

or

Nicardipine infusion, 5 mg/h, titrate up to desired effect by
increasing 2.5 mg/h every 5 minutes to maximum of 15 mg/h

38
Q

Blood Pressure Management in Acute Stroke

Management of blood pressure during and after treatment with rtPA or other acute reperfusion intervention – maintain BP at or below 180/105 mmH

DBP > 140 mmHg or if BP not controlled

A

*Nitroprusside: 0.5mcg/kg/min titrate Q 5min by 0.25mcg/kg/min to max 10mcg/kg/min

39
Q

Stroke: Symptoms

A

Weakness on one side of the body, inability to speak, loss of vision, vertigo, or falling

or

Ischemic stroke is not usually painful, but patients may complain of headache, and with hemorrhagic stroke, it can be very severe.
! Teach FAST (Face, Arm, Speech, Time)

40
Q

Tests for Evaluation of Ischemic/hemorrhagic Stroke

A

CT (  ) of the brain without contrast – most important test to distinguish between hemorrhagic vs. ischemic–Bright White AREA

MRI –high resolution; reveals areas of ischemia earlier Electrocardiogram – A.fib detection

Carotid Doppler (CD) – to detect stenosis/atherosclerosis extracranial

Transcranial Doppler (TCD) – to detect stenosis/atherosclerosis intracranial

TTE/TEE

41
Q

Scales for stroke

A

• National Institutes of Health Stroke Scale (NIHSS)
o Evaluates neurologic impairment on a scale of 1 – 42, with higher scores
indicating severe neurologic impairment. (usually performed at presentation, 24hrs after admission, and again at discharge).

• Modified Rankin Scale (mRS)
o A scoring system for measuring disability; scores of 0-1 indicating no to
minimal disability; scores of 5-6 indicates severe disability or death. (usually performed at presentation, 24hrs after admission, and again at discharge).

• Glasgow Outcome Scale (GOS)
o Measure of functional recovery with 1 indicated death and 5 indicating good
recovery

42
Q

Complications of Acute Ischemic Stroke

A 
Neurological
Cerebral edema 
Hydrocephalus
↑ intracranial pressure (ICP) 
Hemorrhagic transformation Seizures
Medical
Aspiration Hypoventilation 
Pneumonia 
Myocardial ischemia
 Cardiac arrhythmias 
Deep vein thrombosis 
Pulmonary embolism
 Urinary tract infection 
Pressure ulcers
 Malnutrition
43
Q

Cerebral blood flow (CBF):

Normal CBF

Neurological dysfunction

Infarction

Penumbra

A

NormalCBF-50mL/100g braintissue/min-Mean Arterial Pressure 50 to 150mmH

Neurologicaldysfunction-~20mL/100g/min - Ishemia ensues

Infarction- 8-12mL/100g/min–irreversible damage

Penumbra–(~15-20 mL/100g/min; @3-4.5hr): tissue that is ischemic but maintains membrane integrity; potentially salvageable through intervention.

44
Q

Risk Factors: stroke

Non- Modifiable

A

Non- Modifiable

Age
Sex 
Non-caucasian 
Family h/o TIA/ CVA
Low birth weight
45
Q

Risk Factors: stroke

Modifiable

A 
HTN: Most important modifiable risk factor 
Heart disease: A.fib (most important/treatable) & other cardiac diseases
Hyperlipidemia
Diabetes mellitus
Obesity/Physical Inactivity
Tobacco use
Postmenopausal Hormone Therapy
Sickle cell disease
Oral contraceptives
46
Q

Risk Factors: stroke

Potentially Modifiable

A

Drug & Alcohol abuse

Sleep disordered breathing

h/o migraine with aura

47
Q

Transient Ischemic Attack (TIA

A

Transient Ischemic Attack (TIA): Abrupt onset focal neurological deficit that lasts Less than 24 hours usually less than 30min

48
Q

Stroke, Cerebrovascular Accident (CVA

Two Types

A

Ischemic stroke and Intracranial hemorrhagic stroke:

49
Q

Ischemic stroke

A

87% of all strokes
atherothrombotic–>The final result is arterial occasion,DECREASING BLOOD FLOW AND CAUSING ISCHEMIA DISTAL TO THE OCCLUSION

embolic

50
Q

Intracranial hemorrhagic stroke

A

ADRs: warfarin, heparin, ASA, clopidogrel, lytics

cerebral aneurysm
hypertension
arteriovenous malformation

51
Q

Stoke and Women: it was meant to be.

A

E. Gender: Stroke is the third-leading cause of death for women.

• Some of the impact is explained by the fact that women live longer, and thus the
lifetime risk of stroke in those aged 55 to 75 years is higher in women (20%) than
men (17%)

• Female specific risk factors: Oral contraceptive use, Postmenopausal Hormone
therapy, Pregnancy (Preeclampsia / gestational hypertension, gestational
diabetes)

• Risk Factors That Are Stronger or More Prevalent in Women: A.Fib, HTN,

Migraines with aura, HTN, depression, psychosocial stress

52
Q

southeastern US AND stroke

A

Stroke Belt

CardioPulm II (11 decks)

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