Stroke Isaacs Exam 4 Flashcards
What is a stroke?
Acute focal injury to the CNS causing neurological deficits from lack of O2
What are the two recognizable types of ischemic stroke?
Atherosclerosis and embolus
What is the cause of hemorrhagic stroke?
Bleeding from a rupture in the brain. Can be from hypertension or aneurysm
Name the five non-modifiable risk factors for developing a stroke.
Age, family history, male gender, low birth weight, and african american, hispanic, or asian race
Name the three modifiable lifestyle risk factors for developing a stroke.
Drug abuse (alcohol, cocaine), obesity/physical inactivity, and cigarette smoking
What are the four disease states that put someone at higher risk for stroke?
Diabetes, hypertension, hyperlipidemia, and cardiovascular diseases (afib, vascular disease)
Patients with atrial fibrillation should receive primary stroke prevention through rate/rhythm control and anticoagulation for patients with a CHA2DS2-VASc score of
2 or greater
For patients with valvular disease, what is used for primary stroke prevention?
Warfarin to goal INR of 2-3 or 2.5-3.5
An antiplatelet such as aspirin can be used as PRIMARY prevention in:
Women with high cardiovascular risk.
Name key signs of acute stroke?
Facial droop, arm weakness, slurred speech, ataxia, vision changes, headache (more common for hemorrhagic).
What are key diagnostic tools for use in acute stroke?
CT or MRI, BP, O2 sat, BG, BMP, CBC, INR, aPTT, ECG
What is the only thrombolytic approved for acute ischemic stroke?
Tissue plasminogen activator (t-PA), alteplase (Activase)
True or false: Use of alteplase for ischemic stroke may be the difference between life and death for a patient.
False – has no impact on mortality, only improves patient function after stroke.
What patient history criteria may make them ineligible for receiving alteplase?
Age under 18, history of intracranial hemorrhage, previous stroke/head trauma in past 3 mos, GI hemorrhage in past 3 weeks, major surgery last 14 days, MI in past 3 mos
What patient signs or symptoms would make them ineligible to receive alteplase?
BP >185/110, BG under 50, platelets under 100, INR under 1.7, or abnormal aPTT
Within 3 hours of symptom onset
Alteplase may be used up to 4.5 hours after symptom onset IF the patient is not:
> 80 years old, NIHSS >25, on any recent anticoagulants, or has a history of previous stroke with diabetes
How is alteplase dosed for acute ischemic stroke?
0.09 mg/kg IV bolus + 0.81 mg/kg IV infusion over 60 minutes
What are two potential side effects of alteplase?
Bleeding (keep BP
What blood pressure goal do we have for patients who receive tPA (for the first 24 hours)?
Less than 180/105
What is the blood pressure goal for acute ischemic stroke in patients who do not receive alteplase (for the first 24 hours)?
Less than 220/120
How often should BP be checked during the first 24 hours after stroke?
q15mins for 2 hours, then q30mins for 6 hours, then q1h for 16 hours
How is labetalol dosed to control blood pressure acutely in stroke?
Labetalol 10-20mg IV q10-20 min (MAX 300mg)
How is nicardipine dosed to control BP acutely in stroke?
Nicardipine 5mg/hr IV titrated q5min to BP goal (MAX 15mg/hour)
How is nitroglycerine dosed to control BP acutely in stroke?
5mg/hour IV tirtated 2.5mg/hr q5min (MAX 15mg/hr)
What type of antihypertensive medications may be started AFTER 24 hours if BP still elevated?
PO drugs (if able to take) – may resume home therapies.
Why is it vital to check blood glucose before considering tPA?
Hypoglycemia symptoms may mimic stroke and hyperglycemia worsens morbidity AND mortality. Hyperglycemia treated with insulin to maintain BG under 140mg/dL.
What antiplatelets may be used in acute ischemic stroke management?
Aspirin with or without clopidogrel
What ischemic stroke patients should get aspirin?
ALL – unless contraindicated. Give more than 24 hours after tPA if given, immediately if not.
Limited evidence for dual therapy with clopidogrel.
True or false: Anticoagulants play a key role in the acute management of embolic stroke.
False – increased bleeding, no improvement in neurological function or prevention of early recurrent stroke.
What stroke patients should receive VTE prophylaxis?
High risk hospitalized patients with no bleeding contraindications. High risk patients are those with immobilization, cancer, genetic clotting disorder, and VTE history.
What agents may be used for VTE prophylaxis in stroke patients?
Lovenox (and other LMWH), UFH, mechanical prophylaxis
NO NOACs
In hemorrhagic stroke, little can be done pharmacologically to treat acutely. What can be done?
Reversal of causative medications (if anticoagulants), BP control, prevention of vasospasm, anticonvulsants, and VTE prophylaxis
What drug can be given to prevent vasospasm after subarachnoid hemorrhage? What dose?
Nimodipine 60mg PO/NG q4h for 21 days
What patients should receive anticonvulsants after hemorrhagic stroke?
Only patients with a documented seizure
When should hemorrhagic stroke patients receive DVT prophylaxis?
If imaging confirms hemorrhagic stroke has not expanded and patient at high risk for DVT, can start prophylaxis 1-4 days after hemorrhagic stroke with LMWH or UFH. Compression devices possible.
What three drug classes are used for post-ischemic stroke management but not post-hemorrhagic stroke managment?
Antiplatelets, anticoagulants, and statins
What is the goal blood pressure in patients with a history of stroke?
Less than 140/90 according to stroke guidelines
What types of stroke need antiplatelet therapy after acute treatment?
Ischemic, non-embolic stroke
How is aspirin dosed in secondary stroke prevention?
High dose aspirin for 2-4 weeks, then low dose aspirin chronically.
When is clopidogrel 75mg PO daily used for secondary prevention?
In patients truly intolerant to aspirin–second line therapy
What is the other first line therapy for secondary stroke prevention besides aspirin?
Dipyridamole 200mg + aspirin 25mg PO BID
*higher incidence of HA
What other antiplatelets are studied in secondary stroke prevention?
None
True or false: Antiplatelets are recommended in all patients with a history of ischemic, non-embolic stroke without contraindications or high bleeding risk.
True
What patients should receive anticoagulants for secondary stroke prevention?
Patients with embolic stroke due to atrial fibrillation, valvular heart disease, or heart failure
What statin intensity is always used in ischemic stroke patients?
High intensity, consider higher doses even.
Why are antidepressants used prophylactically in stroke patients?
25-50% of patients experience depression after a stroke. They also improve neurological function.
What antidepressants should be avoided in stroke patients?
Paroxetine (anticholinergic SE), TCAs (anticholinergic SE, arrhythmias)
What antidepressants are recommended?
SSRIs including sertraline, fluoxetine, escitalopram, and citalopram
How are the antidepressants generally dosed post-stroke?
Started low and titrated up. Effect may take 2-6 weeks.
