Stroke Flashcards
define stroke
abrupt onset focal neurologic deficit that lasts >24 hours and is of presumed vascular origin
what causes ischemic stroke
interruption of blood flow to the brain due to a clot
occlusion of a cerebral artery
what causes hemorrahgic stroke
uncontrolled bleeding in the brain
what is an embolic ischemic stroke
emboli from intra (another cerebral artery) or extracranial (from somewhere else) arteries
describe carotid stenosis
atherosclerotic plaque rupture — thrombus formation — local occlusion or dislodge as emboli and causes downstream cerebral vessel occlusion
describe cardiogenic embolism
secondary to valvular heart disease
atrial blood stasis — emboli — occlusion of cerebral circulation
describe a transient ischemic attack
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
when is the highest risk for infarction or recurrent tia
90 days after definite tia
cause of neurologic effects in hemorrhagic stroke
initial neurologic edficit due to direct irritant effects of blood in contact with brain tissue
also due to atoxia
causes of cerebral hemorrhage
cerebral artery aneurysm
hypertensive hemorrhage
trauma
drugs
whats the prognosis fo rhemorrhagic stroke
poor
worsened outcomes
modifiable risk factors for stroke
hypertension smoking dyslipidemai diabetes heart disorders- atrial fibrillation hypercoagulability diet, exercise, obesity psycosocial stress intracranial aneurysm alcohol use
non modifiable risk factors
age male family history prior stroke race
clinical presentation of a stroke
one sided weakness trouble speaking vision problems headache - sudden severe unusual dizziness altered level of consciousness
what does face stand for
face -drooping?
arms - raise?
speech - slurred?
time - call 911
time is what in stroke
brain cells
how long is the acute phase
0-7 days
how long is the hyperacute phase
0-24 hours
goals of theapy
stabilization reperfusion supportive measures prevent complications prevent stroke recurrence
four things to treat in the acute phase
blood pressure
fluid,electrolytes, temperature
glucose management
neurological assessment
hypertension is common and transient in acute phase stroke, when do you treat it
only if >220/120 evidence of aortic dissection acute MI pulmonary edema hypertensive encephalopathy reduce 15-25%
what should be the target bp for patients eligible to recieve thrombolytics
<185/<110
gold standard for early reperfusion
thrombolysis with r-tPA (recombinant tissue plasminogen activator)
inclusion criteria for r-tpa
over 18
ischemic stroke causing measurable neurologic deficit
given within 4.5 hrs before symptom onset
exclusion criteria for r-tpa
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
dosing for r-tpa
0.9mg/kg max 90mg over 1 hour 10% iv bolus over 1min
r-tpa monitoring
bp
neurologic response
signs of bleeding/hemorrhage
avoid anticoagulants or antiplatelets for 24 hr
describe endovascular therapy
catherter up femoral artery to cerebrovasculature
stent to retrieve the clot but doesnt leave it in there
what is there evidence for in endovascular therapy
benefit of recanalization rate, early neurologic improvement, functional independence at 90 days
criteria for EVT in addition to r-tpa
over 18
functionally disabling stroke
infarct in major cerebral artery
must be done by experienced neurointerventionalist within 6 hr of stroke onset
when and what dose of asa
160-325 mg daily within 24-48 hours of stroke onset
how does asa benefit post stroke
reduces recurrence within first couple weeks but no difference in long term death
one study showed clopidogrel anda asa reduced the risk of recurrent stroke without increased hemorrhagic stroke but what were the limitations
chinese demographic
given within 12 hours of symptom onset
baseline risks not reported
asa not or the whole time
is asa/clopidogrel combo recomended
no concern of increased bleeding or hemorrhagic transformation
should combo antiplatelet therapy be used
not beyond 90 days for stroke prevention due to lack of benefit in long term secondary prevention and an increased blleding risk
DVT prophylaxis what when adn for who
LMWH or UFH for hospitalized patients with limited mobility
initiate within 24-48 hours
complications of ischemic stroke
infections
dvt/pe
acute phase monitoring
neurologic symptoms - speech, facial symmetry blood pressure electrolytes complications (calf, chest pain) signs of bleeding - inr, hgb, plt
when is carotid endarterectomy for secondary prevention of ischemic stroke recommended
carotid artery stenosis of >70% on the side of neurologic deficit
who is carotid artery angioplasty and stenting restricted to
patients refractory to medical therapy and notsurgical candiates
higher 30 day stroke rate vs carotid endarterectomy
what is recommended for patients with noncardioembolic ischemic stroke or tia to reduce risk of recurrent stroke
antiplatelet agents rath than oral anticoagulation
asa 50-325
clopidogrel if asa CI
most common ae of asa
upper gi discomfort
bleeding
is asa + extended release dipyridamole better for secondary prevention
most costly and inconvenient, increased risk of bleeding but shown to be superior in secondary stroke prevention
dosing of assa + erdp
asa 25
erdp 200 bid
SE of ERDP
headache decreases after several days
dyspepsia
nausea
diarrhea
ae of clopidogrel
diarrhea
rash
less gi bleed than asa
when would you use clopidogrel
cant tolerate asa or had a recurrent stroke on asa
is warfarin recommended in noncardioembolic ischemic stroke
not superior to asa
increased bleeding risk
recommendations for secondary prevention in cardioembolic stroke
wafarin
apixaban
dabigatran
if unable to take anticoagulants asa is recommended addition of clopidogrel may be reasonable
how do you initiate warfarin after cardioembolic stroke
start within 1-2 weeks use asa until inr target 2.5
cautions with direct oral anticoagulants
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
other secondary prevention measures
blood pressure lowering statin therapy - recommended for most patients diabetes management lifestyle changes depression screening
lifestyle changes
smoking cessation avoid alcohol consumption increase physical activity weight loss diet less saturated fat
