Stroke Acute - Fister Flashcards
Initial Management Prevention of Neurologic Complications Prevention of Systemic Complications Secondary Stroke Prevention Transition of Care
Time restraints on reperfusion therapies: (3)
- IV rtPA alone < 4hours
- IA therapy: IA tPa and/or intraarterial mechanical thrombectomy.
- With basilar artery thrombus, window may be up to 8hrs
Which study was initial tPa study in 1995?
Patients treated with recombinant tissue plasminogen activator within 3 hours of onset were ?% more likely to have minimal or no disability at 3 months.
Landmark study
30%
What are the 5 contraindications for tPA after 3h window has passed?
- NIHSS > 25
- > 80 yoa
- Those taking oral anticoagulants
- History of stroke
- History of diabetes
Patients with NIHSS < _____ and age < _____ had the greatest potential for excellent outcomes after treatment with IV tPa
20, 75yoa –> mild to moderate stroke
Any intracranial hemorrhage occured in ___% of patients who received IV rtPA
6.4%; (however mortality rates were similar.
Which stroke subtype showed better outcomes after IV rtPa?
Small vessel disease.
Define ischemic penumbra
Hypoperfused area of focal ischemia that may be salvaged by timely intervention.
– the area immediately surrounding the core of infarct where blood flow is sufficient, for the moment, to maintain cellular viability, but not sufficient for normal cellular function.
**rationale for permissive HTN
What is the current guideline for permissive HTN
220/120. Less if received IV tPa. Rule used to be x 2 weeks. Now more clear that not really necessary >48h. Regardless, once in acute rehab, can have normal BP control.
What component of vitals is detrimental during acute peri-stroke period?
fever
Acute elevations in ____ are common in Stroke. In what % of the stroke population? resolves spontaneously after _____
BP; 85%, 24-48hr
Acutely lowering blood pressure during stroke can _____
can expand the area of ischemia – penumbra
What is the current AHA guidelines for lowering blood pressure after stroke?
lower by 15% over the first 24h; permissive up to 220/120 unless tPa has been given.
______ therapy should be initiated 24h post tPa
antiplatelet therapy
two potential complications of a cerebellar infarct
- acute hydrocephalus - always assess the 4th ventricle for patency
- elevated ICP due to space occupying edema which could be life threatening given tiny vault with no room for swelling.
HAMLET, DESTINY, AND DECIMAL trials are all regarding ____. What is the DESTINY 2 trial?
three pooled randomized trials that basically said hemicraniectomy is life-saving within 48h of event. NNT 2. DESTINY 2 gives extra contraindications for those patients >60.
Cincinnati hemicraniectomy protocol:
- Age _____ years
- If greater than 60 years use _____
- NIHSS > _____
- > ____% of MCA territory on CT
- Agreement of _____
- NS involvement if: (2 things)
- Minimum of _____ hours since tPA
- 18-60 years
- DESTINY 2
- 10
- 50%
- family
- Clinical deterioration, including subtle decrease in arousal, >4mm shift increase
- Minimum of 6 hours since rtPA
what are the two most common post-stroke systemic complications
- Aspiration pna
2. PE
Bacterial pneumonia causes ____% of stroke related deaths
15-25%
What 4 factors place stroke patients at high risk for bacterial pneumonia
- reduced consciousness
- impaired gag or swallow problems
- 20-25% with dysphagia may result in aspiration
- 7x more likely in patients who aspirate
Stroke patients who get pneumonia can potentially see what 3 outcomes?
- longer hospital stays
- readmissions
- 3 fold increase in mortality
(mortality can be as high as 65% if patient has aspiration pneumonia)
What 6 factors must be checked prior to advancing to swallow challenge?
- strong clear voice (no dysphonia)
- Manages own secretions, no suction required
- Understandable speech (no dysarthria)
- Absent facial droop
- Normal voluntary cough
- Normal gag reflex
14 warning signs of dysphagia
- coughing with signs of struggle
- fever (24-48h after stroke)
- wheezing
- wet vocal quality
- refusal to take foods/liquids
- changes in respirations
- watering eyes
- excessive drooling
- gagging
- pocketing of food in mouth
- facial grimacing
- sudden change of color in face/lips
- smell of formula on breath
- increase residuals
DVT prophy initiated by ____
end of day 2 (48h)
4 pathways/etiologies of ischemic stroke
- atherothrombotic cerebrovascular disease (30-40%)
- Cryptogenic (25-30%)
- Lacunar - small vessel disease (20-30)
- cardioembolic (20-25%)
2 most common pathways/etiologies of hemorrhagic stroke
- ICH (70%)
2. SAH (30%)
4 “major” risk factors for stroke by way of Large vessel atherothrombotic cerebrovascular disease
- HTN
- HLD
- Tobacco abuse
- Diabetes
4 “major” risk factors for lacunar strokes (small vessel)
- HTN
- Diabetes
- tobacco abuse
- age
5 types of cardioembolic sources
mechanical valve Ventricular or atrial thrombus Afib**** bacterial endocarditis MI
three sources of paradoxical embolus
atrial septal aneurysm
patent foramen ovale PFO
ASD
8 types of hypercoagulable disorders that could lead to stroke
thalassemia sickle cell antithrombin III deficiency Protein C,S deficiency Antiphospholipid syndrome Factor V leiden mutation prothrombin gene mutation systemic malignancy
three most common causes of intracerebral hemorrhage
- HTN
- amyloid angiopathy in the elderly
- vascular malformation
amyloid angiopathy will present as what type of stroke (region)
lobar
What are the 4 most common areas for Hypertensive bleed
- BG
- pons
- thalamus
- cerebellum
2 most common causes of non-traumatic SAH
- aneurysmal
2. AVM
watershed or “boundary zone” infarcts are a result of what type of stroke.
Frequently associated with: _____
- hypotensive stroke - any event causing an abrupt drop in blood pressure. which critically compromises cerebral blood flow (ACA/MCA border zone)
- Carotid stenosis.
Hemorrhagic conversion often results due to:
arterial occlusion causes ischemia to capillaries, arterioles, and vascular walls in addition to deleterious effects on neurons. Hemorrhage results when the “fragile” or “injured” vessels rupture.
hemorrhagic transformation occurs: _____ days and ____% of non-complicated ischemic strokes
2-14 days post ictus
5%
Proposed mechanisms of hemorrhagic transformation include:
- reperfusion either from recanalization or collateral circulation
- disruption of BBB
3 risk factors for hemorrhagic conversion (in order)
name 5 lesser risk factors
- Large stroke
- embolic
- older age
uncontrolled DM, labile blood pressure, richness of collateral circulation, use of anticoagulants, treatment with thrombolytic agents
Regarding dual anteplatelet therapy
90 optimal when
14-21 days optimal when
symptomatic IC stenosis
otherwise – POINT trial
