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Clinical 2.0 > Stroke > Flashcards

Stroke Flashcards

1
Q

define stroke

A

abrupt onset focal neurologic deficit that lasts >24 hours and is of presumed vascular origin

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2
Q

what causes ischemic stroke

A

interruption of blood flow to the brain due to a clot

occlusion of a cerebral artery

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3
Q

what causes hemorrahgic stroke

A

uncontrolled bleeding in the brain

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4
Q

what is an embolic ischemic stroke

A

emboli from intra (another cerebral artery) or extracranial (from somewhere else) arteries

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5
Q

describe carotid stenosis

A

atherosclerotic plaque rupture — thrombus formation — local occlusion or dislodge as emboli and causes downstream cerebral vessel occlusion

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6
Q

describe cardiogenic embolism

A

secondary to valvular heart disease

atrial blood stasis — emboli — occlusion of cerebral circulation

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7
Q

describe a transient ischemic attack

A

temporary docal neurologic deficit lasting less than 24 hr as a result of dimished or absent blood flood
no residual neurologic deficit
absence of acute infarction or recurrent tia

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8
Q

when is the highest risk for infarction or recurrent tia

A

90 days after definite tia

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9
Q

cause of neurologic effects in hemorrhagic stroke

A

initial neurologic edficit due to direct irritant effects of blood in contact with brain tissue
also due to atoxia

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10
Q

causes of cerebral hemorrhage

A

cerebral artery aneurysm
hypertensive hemorrhage
trauma
drugs

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11
Q

whats the prognosis fo rhemorrhagic stroke

A

poor

worsened outcomes

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12
Q

modifiable risk factors for stroke

A 
hypertension 
smoking 
dyslipidemai 
diabetes
heart disorders- atrial fibrillation 
hypercoagulability 
diet, exercise, obesity 
psycosocial stress
intracranial aneurysm
alcohol use
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13
Q

non modifiable risk factors

A 
age 
male
family history 
prior stroke
race
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14
Q

clinical presentation of a stroke

A 
one sided weakness 
trouble speaking 
vision problems
headache - sudden severe unusual
dizziness
altered level of consciousness
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15
Q

what does face stand for

A

face -drooping?
arms - raise?
speech - slurred?
time - call 911

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16
Q

time is what in stroke

A

brain cells

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17
Q

how long is the acute phase

A

0-7 days

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18
Q

how long is the hyperacute phase

A

0-24 hours

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19
Q

goals of theapy

A 
stabilization 
reperfusion
supportive measures 
prevent complications
prevent stroke recurrence
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20
Q

four things to treat in the acute phase

A

blood pressure
fluid,electrolytes, temperature
glucose management
neurological assessment

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21
Q

hypertension is common and transient in acute phase stroke, when do you treat it

A 
only if >220/120
evidence of aortic dissection 
acute MI 
pulmonary edema
hypertensive encephalopathy 
reduce 15-25%
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22
Q

what should be the target bp for patients eligible to recieve thrombolytics

A

<185/<110

23
Q

gold standard for early reperfusion

A

thrombolysis with r-tPA (recombinant tissue plasminogen activator)

24
Q

inclusion criteria for r-tpa

A

over 18
ischemic stroke causing measurable neurologic deficit
given within 4.5 hrs before symptom onset

25
Q

exclusion criteria for r-tpa

A

only minor or rapidly improving stroke symptoms
condition that could increase risk of major hemorrhage
active hemorrhage
recent major surgery
SBP >185 or DBP>110 refractory to antihypertensives

26
Q

dosing for r-tpa

A

0.9mg/kg max 90mg over 1 hour 10% iv bolus over 1min

27
Q

r-tpa monitoring

A

bp
neurologic response
signs of bleeding/hemorrhage
avoid anticoagulants or antiplatelets for 24 hr

28
Q

describe endovascular therapy

A

catherter up femoral artery to cerebrovasculature

stent to retrieve the clot but doesnt leave it in there

29
Q

what is there evidence for in endovascular therapy

A

benefit of recanalization rate, early neurologic improvement, functional independence at 90 days

30
Q

criteria for EVT in addition to r-tpa

A

over 18
functionally disabling stroke
infarct in major cerebral artery
must be done by experienced neurointerventionalist within 6 hr of stroke onset

31
Q

when and what dose of asa

A

160-325 mg daily within 24-48 hours of stroke onset

32
Q

how does asa benefit post stroke

A

reduces recurrence within first couple weeks but no difference in long term death

33
Q

one study showed clopidogrel anda asa reduced the risk of recurrent stroke without increased hemorrhagic stroke but what were the limitations

A

chinese demographic
given within 12 hours of symptom onset
baseline risks not reported
asa not or the whole time

34
Q

is asa/clopidogrel combo recomended

A

no concern of increased bleeding or hemorrhagic transformation

35
Q

should combo antiplatelet therapy be used

A

not beyond 90 days for stroke prevention due to lack of benefit in long term secondary prevention and an increased blleding risk

36
Q

DVT prophylaxis what when adn for who

A

LMWH or UFH for hospitalized patients with limited mobility

initiate within 24-48 hours

37
Q

complications of ischemic stroke

A

infections

dvt/pe

38
Q

acute phase monitoring

A 
neurologic symptoms - speech, facial symmetry 
blood pressure
electrolytes
complications (calf, chest pain) 
signs of bleeding - inr, hgb, plt
39
Q

when is carotid endarterectomy for secondary prevention of ischemic stroke recommended

A

carotid artery stenosis of >70% on the side of neurologic deficit

40
Q

who is carotid artery angioplasty and stenting restricted to

A

patients refractory to medical therapy and notsurgical candiates
higher 30 day stroke rate vs carotid endarterectomy

41
Q

what is recommended for patients with noncardioembolic ischemic stroke or tia to reduce risk of recurrent stroke

A

antiplatelet agents rath than oral anticoagulation
asa 50-325
clopidogrel if asa CI

42
Q

most common ae of asa

A

upper gi discomfort

bleeding

43
Q

is asa + extended release dipyridamole better for secondary prevention

A

most costly and inconvenient, increased risk of bleeding but shown to be superior in secondary stroke prevention

44
Q

dosing of assa + erdp

A

asa 25

erdp 200 bid

45
Q

SE of ERDP

A

headache decreases after several days
dyspepsia
nausea
diarrhea

46
Q

ae of clopidogrel

A

diarrhea
rash
less gi bleed than asa

47
Q

when would you use clopidogrel

A

cant tolerate asa or had a recurrent stroke on asa

48
Q

is warfarin recommended in noncardioembolic ischemic stroke

A

not superior to asa

increased bleeding risk

49
Q

recommendations for secondary prevention in cardioembolic stroke

A

wafarin
apixaban
dabigatran
if unable to take anticoagulants asa is recommended addition of clopidogrel may be reasonable

50
Q

how do you initiate warfarin after cardioembolic stroke

A

start within 1-2 weeks use asa until inr target 2.5

51
Q

cautions with direct oral anticoagulants

A

new to market less real world experience
no measure of anticoagulation state
no reversible agent if cases severe
not approved for patients with valvular AF
safety post thrombolytic unknown

52
Q

other secondary prevention measures

A 
blood pressure lowering 
statin therapy - recommended for most patients 
diabetes management
lifestyle changes
depression screening
53
Q

lifestyle changes

A 
smoking cessation
avoid alcohol consumption 
increase physical activity 
weight loss
diet less saturated fat

Clinical 2.0 (24 decks)

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