Stroke Flashcards
Hemorrhagic Stroke: Clinical presentation
Worst headache of your life and decreased level of conscientious.
other details,
headache, dizziness, seizures, vomiting, neck rigidity
Hemorrhagic Stroke:
Intracerebral hemorrhage
Secondary Causes
uncontrolledbloodpressure ,antithrombotic or thrombolytic
agents
Hemorrhagic Stroke:
Subarachnoidhemorrhage (SAH)
A. Blood enters cerebrospinal fluid
B. Secondary to trauma, rupture of an intracranialaneurysm ,or rupture of an arteriovenous malformation (AVM)
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
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
Nimodipine (Nimotop): Black Box Warning
Do not administer intravenously or parenterally. Will cause Death and Serious ADR.
Secondary Prevention: Non-Cardioembolic TIA/Stroke
Artherothrombotic, lacunar, or cryptogenic
What drugs are available and what dose?
Aspirin 50-325 PO daily –Cheap *best
ASA 25 mg /Dipyridamole ER (Aggrenox) 200mg PO BID*ok
Clopidogrel 75mg PO daily *last
Secondary Prevention: Non-Cardioembolic TIA/Stroke
What’s better ASA or ASA/dipyridamole( Aggrenox)?
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.
Secondary Prevention: Non-Cardioembolic Stroke/TIA
What about long term, Dual anti-playlet therapy?
Combo of ASA and Clopidegrel–> is not recommneed
BUT** DAPT is indicated if history of ACS/PCI –> look for stent or intracranial stenosis.
Secondary Prevention: Cardioembolic Stroke
Use CHADs VASc:
Anticoagulation:
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
Primary and Secondary Prevention of Stroke
Hypertension
Drugs and Goals?
ACEI + Thiazide or ARB
Goal
Primary and Secondary Prevention of Stroke
Lipid Management: SPARCL (ATV 80 vs. PLB)
Drugs, situation, and goals
ATV 40-80 mg daily and ROSVA 20-40 mg daily
Stroke only from artherosclorisis.
Decrease in LDL of at least 50% from baseline
Primary and Secondary Prevention of Stroke
Diabetes mellitus with risk or history of CVD
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
Primary and Secondary Prevention of Stroke
Antiplatelet Treatment – Primary Prevention
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
Primary and Secondary Prevention of Stroke:
Obesity/Ethanol Use
Weight management program
Exercise program Healthy diet with increased fruits/ vegetables
Limit alcohol intake
Obesity
Goal body mass index 18.5- 24.9 kg/m2
Ethanol
≤ 2 drinks (males)
≤ 1 drink (non-pregnant females)
Primary and Secondary Prevention of Stroke:
Tobacco
Bupropion
Nicotine patch/ gum
Varenicline
Nonpharmacologic management`
Acute Ischemic Stroke – Treatment
General Treatment Principles
- To identify candidates for thrombolytics within 4.5 hours**
- Close monitoring of patient for change in metal status
General Treatment Interventions for Acute Ischemic Stroke
Fluid management: Dehydration and Hypotension
Hyperglycemia: maintain range of 140-180 mg/dL
Hypoglycemia: (38C
Hypertension : mentioned later
DVT/PE prevention: “”
Pharmacologic Treatment of Acute Stroke
Drug/Amistration/BP/other drug??
(r-tPA) alteplase- (Activase® )
• Half life 3-8 minutes
- Dose: 0.9mg/kg (maximum 90mg)
- the first 10% given IV bolus
- remaining 90% given by continuous infusion over 1 hour.
- BP
(r-tPA) alteplase- (Activase® )
ADR and Precautions
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
(r-tPA) alteplase- (Activase® )
Monitoring
Monitoring Parameters: BP, Neurologic function, bleeding: 1.q15min X 2hrs 2. Then q30min x 6 hrs 3. Then q60min x 24 hrs 4. qshift
NINDS r-tPA Stroke Study Group study:
Excustion Critieria
- History of previous intracranial hemorrhage
- Elevated blood pressure > 185/110
- Platelet count 1.7 or PT >15 seconds
- 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
- Blood glucose concentration
NINDS r-tPA Stroke Study Group study:
Inclusion Critieria
- Treatment within 45 minutes
- age > 18
- ishemic stroke with measurable neuralgic deficit
NINDS r-tPA Stroke Study Group study: (3 hour window)
Relative excision criteria
- minor or rapidly improving stroke symptoms
- Pregnacy
- MI within 3 months
- any trauma or surgery within 14 days
- UTI or GI hemorrhage within 21 days
ECASS Study:
Additional exclusion criteria if within 3-4.5 hours of onset.
! Patient > 80 years
! Those taking oral anticoagulant regardless of their INR
! Baseline NIHSS score > 25
! Those with hx of stroke and diabetes
ECASS Study: Expansion of the Time Window for Tx of Acute Ischemic Stroke with r-tPA
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
NINDS r-tPA Stroke Study Group study:
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
Acute Ischemic Stroke: Antiplatelet agents
Aspirin
• 325 mg within 48 hours after stroke onset
Wait 24 hours if tPA was used
Acute Ischemic Stroke: Antiplatelet agents
DAPT
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
Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH
- 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
Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH:
AFib
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
Acute Ischemic Stroke: antithrombotic tx for prevention of DVT/PE
Low dose UFH/LMWH should be restricted for 24 hours after administration of thrombolytic therapy.
low dose has less risk of intracrannial hemorrhage
Blood Pressure Management in Acute Stroke
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
Blood Pressure Management in Acute Stroke
Agents :Indication that patient is eligible for treatment with intravenous rtPA
SBP >185mmHg or DBP>110mmHg
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
Labetalol ADR
Labetalol: Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension
Nicardipine ADR
Nicardipine: Tachycardia, headache, flushing, local phlebitis
Nitroprusside ADR
Nitroprusside: Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication
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
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
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
*Nitroprusside: 0.5mcg/kg/min titrate Q 5min by 0.25mcg/kg/min to max 10mcg/kg/min
Stroke: Symptoms
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)
Tests for Evaluation of Ischemic/hemorrhagic Stroke
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
Scales for stroke
• 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
Complications of Acute Ischemic Stroke
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
Cerebral blood flow (CBF):
Normal CBF
Neurological dysfunction
Infarction
Penumbra
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.
Risk Factors: stroke
Non- Modifiable
Non- Modifiable
Age Sex Non-caucasian Family h/o TIA/ CVA Low birth weight
Risk Factors: stroke
Modifiable
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
Risk Factors: stroke
Potentially Modifiable
Drug & Alcohol abuse
Sleep disordered breathing
h/o migraine with aura
Transient Ischemic Attack (TIA
Transient Ischemic Attack (TIA): Abrupt onset focal neurological deficit that lasts Less than 24 hours usually less than 30min
Stroke, Cerebrovascular Accident (CVA
Two Types
Ischemic stroke and Intracranial hemorrhagic stroke:
Ischemic stroke
87% of all strokes
atherothrombotic–>The final result is arterial occasion,DECREASING BLOOD FLOW AND CAUSING ISCHEMIA DISTAL TO THE OCCLUSION
embolic
Intracranial hemorrhagic stroke
ADRs: warfarin, heparin, ASA, clopidogrel, lytics
cerebral aneurysm
hypertension
arteriovenous malformation
Stoke and Women: it was meant to be.
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
southeastern US AND stroke
Stroke Belt
