Stroke - Dr. Lanier Flashcards
Dr. Lanier EXAM V
What are the different types of strokes?
-Acute ischemic stroke (cerebrovascular accident CVA - 87%)
-Hemorrhagic stroke (13%)
Subarachnoid: rupture of the intracerebral aneurysm
intracranial: bleeding into the parenchyma
-Cryptogenic stroke
-Transient ischemic stroke (TIA): symptoms improve within 24h, no image in infarction
What are Cryptogenic strokes
The cause of the stroke is unknown
Risk factors for strokes
-Hypertension #1
-Diabetes
-Arrhythmias
-Smoking
-Physical inactivity
-Nutrition
-Genetics
-Anxiety, depression
What causes the stroke?
-Carotid plaque from emboli that breaks off within the arteries
-Carotid stenosis: narrowing of the arteries -> reduced blood flow -> Ischemia (lack of oxygen to the brain)
-Atrial fibrillation
-> RESULTS in cell death (irreversible)
Women-specific risk factors
-Women are older when they have their strokes
-early menopause
-use of oral contraceptives
-use of estrogen or progestin
-pregnancy or first 6 weeks after pregnancy
Stroke signs and symptoms
!!!
-depends on the area of the brain involved
-weakness on one side
-inability to speak
-Aphasia (language disorder caused by damage in the brain)
-loss of vision, a feeling of vertigo
-severe headache (more often in hemorrhagic stroke)
-hemi or monoparesis
-altered level of consciousness
Acronym BE FAST
!!
Balance
Eyes (loss of visual field)
Facial dropping: numbness, uneven smile
Arm weakness: weak or numb, arm drift
Speech: slurred speech
Time is brain (the longer, the more damage -> Call 911)
What is used to assess the severity of a stroke?
-National Institute of Health Stroke Scale (NIHSS)
-from 0 to 42 - the more the worse
-ABCD (Age, BP, clinical features, duration of symptoms, diabetes)
Within what time frame must the NIHSS score be done?
within 12 hours
Why is the NIHSS score done?
To determine the appropriate therapy
What parameters are used for TIA (transient ischemic stroke)?
-Age: 60 or older
-BP: admission BP > 140/90
-Clinical features: what type of issues -> verbal? mono paresis (loss of function of one limb) or hemiparesis (one-sided muscle weakness)
-Duration of symptoms: 30 min, 30-60 min, >60 min -> 2 points in scoring
What score is the cut-off when deciding between anticoagulant and antiplatelet therapy? !!!
between Minor and moderate stroke
-1-5: Minor stroke
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
-6-15: moderate stroke
Which imaging tests are used to identify a stroke?
-Computed tomography (CT)
shows infarction within 24 hours
uses radiation
quick, cheap, and easy
-Magnetic Resonance Imaging (MRI)
shows infarction within minutes
causes anxiety though (claustrophobia)
more accurate
hardware inside the body is contraindicated
Which of the imaging tests should be done first?
CT scan
-it quickly shows if there is a bleed (hemorrhagic stroke) -> AVOID blood-thinner
-infarction reveal may take up to 24h: tells us where the ischemia has occurred
What is the penumbra pattern?
-on MRI
-shows the salvageable tissue (can be reversed with pharmacotherapy therapy)
-shows the area that is dead
Which agents are used acutely?
Thrombolytics
-Alteplase
-Tenecteplase
pt who do not qualify for Thrombolytics will use Antiplatelets:
-Aspirin
-Aspirin/dipyridimole
-P2Y12 inhibitors (clopidogrel, ticagrelor)
Secondary treatment of strokes
-pt who do not qualify for Thrombolytics will use Antiplatelets:
-Aspirin
-P2Y12 inhibitors (clopidogrel, ticagrelor)
-Aspirin/dipyridamole (not often used)
-GIIb/IIIa?: new data
-Antihyperlipidemic
-Anti-HTN
What is the MOA of Alteplase?
!!!
-it is a serine protease that converts Plasminogen into Plasmin
-Plasmin cuts fibrin -> breaks up the clot
What is the dose of Alteplase?
!!!
-0.9 mg/kg based on TBW
-Max: 90 mg !!!
How is Alteplase administered?
!!!
-start with 10% of the initial dose bolused over 1 minute
-remainder 90% of the dose infused over 1 hour
-> BOLUS is needed due to short-halflife
Indication of Alteplase/Tenecteplase
-18yo
-disabling ischemic stroke with NIHSS of at least 6, including severe strokes within 3hrs
-recommended within the first 3hrs of onset
-blood glucose >50 mg/dl (CHECK FIRST!!!), if <50 and corrected -> can still give the drug
-can be given with mono or dual antiplatelet therapy
What is the ideal time frame within Alteplase/Tenecteplase should be given?
Within 3 hrs (also 3-4.5 h)
-may also be effective when given up to 4.5 h, and the symptoms have occurred >4.5 h (eg during sleep) - ONLY if the MRI reveals that the tissue can be saved (FLAIR image)
-it starts with the last time the patient recalls normal function
Which NIHSS score should the patient have for Altaplese/Tenectaplese therapy?
At least 6
Which lab has to be checked before giving Alteplase/Tenecteplase?
!!!!
Blood glucose
-patients with hypoglycemia may have signs of a stroke -> when given to those patients, they are at risk of bleeding
What should the BP be before giving anti-thrombolytics?
less than 185/110
-still give the drug if troponin is not on baseline or EKG is off
What are additional indications
Thrombolytics can still be given when:
Contraindications for Thrombolytics
!!!
-mild nondiasbling stroke (NIHSS 0-5)
-acute intracerebral brain hemorrhage (ICH) - brain bleed, we dont want to make the blood more thin and increase the risk of bleeding
-history of bleeding in the head
-head trauma or ischemic stroke within 3 months
-intracranial/spinal surgery within 3 months
-GI bleed or GI cancer diagnosis in !! last 21 days !!
-full dose DOACS (dabigatran, heparin, enoxaparin), prophylactic is fine though
-IV Aspirin or abciximab
-infective endocarditis
-aortic arch dissection
-intra-axial intracranial neoplasm
-Coagulopathy: high values
platelets >100 000
INR > 7
aPTT > 40
PT > 15
give the drug, don’t wait for the results, stop the drug if the results are high
Which drugs should not be given with thrombolytics?
-IV Aspirin
-Glycoprotein IIb/IIIa inhibitors: eptifibatide or tirofiban
-Abciximab
-Enoxaparin: alteplase should NOT be given if received a full dose within 24 hr
How are patients monitored after receiving thrombolytics?
Post-thrombolytic monitoring
-pt receiving alteplase will be monitored for at least 24 h in the ICU
-maintain BP <180/105 for 24h after thrombolytic (measure BP ev 15 min-> ev 30 min -> ev 1h to make sure BP is not increasing too much to prevent hemorrhagic transformation)
-repeat CT after 24h and make sure there is no bleeding
-if headache nor N/V develop, recommend emergency CT scan
-hold NG (nasogastral) tubes, bladder catheter if possible
What to test for before starting anticoagulants after thrombolytic therapy?
CTI or MRI 24h after thrombolytics before starting anticoagulants or antiplatelets
What to look out for in the first 24 h during antithrombolytic therapy?
-hemorrhagic conversion
-angioedema
-system bleeding
MOA and indication of Tenectaplese
-same as alteplase: converts plasminogen to plasmin -> cuts Fibrin
-indicated for MI used off-label for ischemic stroke
-mutated version of alteplase -> longer half-life
Dose of Tenectaplese
for MI: 0.5 mg/kg
for ischemic stroke: 0.25 mg/kg TBW (Max: 25 mg) !!!
guideline indication: for patients eligible for mechanical thrombectomy - but used off-label for ischemic stroke
Difference between alteplase and tenecteplase
-tenecteplase is
-has a longer half-life
-resistance to plasminogen-activator inhibitors is greater
-fibrin-specificity is greater
-dosing is simple -> one-time bolus vs 10% -> 90%
-cheaper (7000$ vs 10 000$9
What did the TIMELESS and TWIST study come up with?
when it comes to treating patients beyond the 4.5 h after stroke symptoms range, tenecteplase did not have better outcomes than placebo
What is the BP cut-off that does not require BP treatment within the first 48-72h after a stroke?
NON-THROMBOLYTIC THERAPY:
-if less than 220/120 mmHg don’t treat for 48-72h
-> the idea is that at the time of ischemic stroke blood flow to the brain is blocked, a high BP allows blood flow through a narrow artery
-if higher than 220/120 reduce by 15% in the first 24h
Which drugs are used to treat high BP during the acute phase of stroke therapy?
-rapid-acting: Labetalol, Hydralazine
-continuous infusion (drip): Nicardipine, Clevidipine
Secondary Prevention of strokes
Antiplatelets
-prevent another stroke
-patients without thrombolytics should have dual therapy (DAPT) within 24-48 to 72 hours
-patients with thrombolytics should get monotherapy after 24 hours:
Aspirin, Clopidogrel, Aspirin/Dipyridamole
-patients with mild stroke (low NIHSS) or high ABCD -> DAPT therapy (short-term)
Aspirin 81 mg + Clopidogrel 75 mg
Aspirin 81 mg + ticagrelor 90 mg BID
MOA for Aspirin and P2Y12 inhibitors
Aspirin: inhibits COX-1 -> no platelets
P2Y12i: inhibits ADP -> no P2Y12 activation
P2Y12i : Clopidogrel, Ticagrelor, Prasugrel, Cangrelor…
Things to AVOID during secondary prevention therapy
-don’t use anticoagulants, don’t switch to Warfarin
-increasing the dose of Aspirin is not effective (only increases the risk of bleeding)
-don’t put on triple therapy:
Aspirin + clopidogrel + dipyridamole
What is the loading dose of DAPT in treating stroke?
-antiplatelets for secondary prevention or when not eligible for thrombolytic
Loading dose:
Aspirin 162-325 mg + Clopidogrel 300 mg
Aspirin 162-325 mg + Ticagrelor 180 mg
Maintenance dose:
Aspirin 81 mg + Clopidogrel 75 mg
Asprin 81 mg + Ticagrelor 90 mg
What NIHSS score is preferred in which DAPT therapy?
Aspirin + Clopidogrel:
NIHSS: 3 or less
ABCD: 4 or more
Aspirin + Ticagrelor:
NIHSS: 5 or less
ABCD: 6 or more
What is the duration time of DAPT?
Aspirin + Clopidogrel: 21 days then -> SAPT
Aspirin + Ticagrelor: 30 days then -> SAPT
How is Clopidogrel metabolized?
prodrug -> activated by CYP2C19
-in patients with loss of function for CYP2C19,
ticagrelor is more effective since it is more potent
-in patients who are strong Cyp3A4 inducers, clopidogrel is better
-but Aspirin + clopidogrel was not less effective and it is safer in terms of bleeding risk since ticagrelor is more potent
Treating stenosis of major intracranial artery
-TIA/stroke result (50-99%)
Aspirin 325 mg daily MONOTHERAPY
Treating severe stenosis
FYI?
-stenosis (70-99%) of major intracranial artery within 30 days
-consider DAPT with clopidogrel for 90 days
-consider ticagrelor with >30% stenosis, for 30 days
When are patients disqualified from DAPT therapy?
When they are on anticoagulant therapy
-they can only start antiplatelets on top of anticoagulants if the stroke is non-cardio-embolic -> BUT hold the anticoagulant until conformation that the stroke is not hemorrhagic
-may benefit when there is an indication (coagulopathy eg antiphospholipid syndrome) -> warfarin
What is the goal BP in patients with hemorrhagic stroke?
SBP of 150-220 mmHg
SBP <140 is not preferred -> less perfusion
SBP > 220 -> lower with continuous infusion (to prevent further spread of the hemorrhage in the brain)
What drugs to use in Afib
-DOACS (apixaban, rivaroxaban, dabigatran)
restart anticoags
-minor strokes: within 48 h
-major strokes likely within 7 days
if the stroke is caused by Afib -> DOAC is enough - don’t add antiplatelet
if it is from carotid artery stenosis or arteriosclerosis -> adding antiplatelet may be beneficial
What to do in hemorrhagic transformation?
Ischemic stroke -> turns into hemorrhagic stroke (bleeding)
-stop antiplatelets until the bleeding is controlled
-antiplatelet may be restarted later
Lipid-lowering drugs
-patients (75 and younger) after stroke should be on a high-intensity statin
-75 and older: moderate or high-intensity
-if statin is maximized and goal (<70 LDL) is not reached -> add ezetimibe (Zetia) or PSK9 inhibitor
When are lipid-lowering drugs contraindicated?
-when patients are on dialysis
-controversial in hemorrhagic stroke (may increase risk of bleeding, use Rosuvastatin or pravastatin if needed)
Triglyceride and LDL
Triglycerides 135 - 499 mg/dl and LDL 41-100
icosapent ethyl (omega-3) 2 mg BID
Triglycerides >500: omega-3 +/- fibrates
HTN goals
no history of HTN: treat when >130/80
history of HTN: get to <130/80
-Thiazides, ACEi/ARBs (or combi of both)
2nd line: CCB, MAR
Is the patient eligible for thrombolytics?
-GI bleeding in the last 21 days?
-full dose DOACS (dabigatran, heparin, enoxaparin)
-IV aspirin or abciximab
-onset within 3 to 4-5 hf
-NIHSS score
-and more
What disqualifies the patient from DAPT after thrombolytic therapy?
-if the patient has received thrombolytic -> NO DAPT
-NIHSS and ABCD score: <3/>4 and <5/>6
Question
What is the LDL goal
You said to treat the patient to LDL even though is he is below 70?
