Stroke -Issacs Flashcards
Type of Stroke
Ischemic (Atherosclerotic or Embolic-
Cardio/A.Fib)
or
Hemorrhagic
what does CHA(2)DS(2)VASc stand for
CHF HTN Age (>/= to 75 years) Diabetes Stroke/TIA Vascular disease (MI, aortic plaque, PAD) Age (64- 75 years) Sex (female = 1 pt)
Managing Risk Factors:
How ot control A.Fib
Control Rate/Rhythm
Anticoag for high risk pts with A.Fib (use CHADSVASC)
Managing Risk Factors:
Valvular Disease
use warfarin if valve replacement
Managing Risk Factors:
Alcohol use:
_____ drinks per day
= 2 drinks/day
who is recommended to get aspirin 81 mg QD for primary prevention of stroke
WOMEN with high CV risk
clinical presentation of stroke
- dysphasia (difficulty speaking)
- facial droop
- unilateral/bilateral weakness
- Ataxia (inability to coordinate muscle movement)
- Vision changes (diplopia)
- HA 9more common with hemorrhagic)
Glycemic Control and Stroke:
Why manage Hypoglycemia?
Why manage Hyperglycemia?
hypo: could be causing the altered mental status
hyper: in acute stroke situations BG over 180can result in worse outcomes (morbidity and mortality)
Thrombolytics have no impact on _____ but can improve ________
no impact on MORTALITY; improve neurologic function
What is the Inclusion Criteria for t-PA
- NOT hemorrhagic stroke (must have dx of ischemic stroke)
- Sx onset < 3 hrs ago
- > 18 years old
What is the Exclusion Criteria for t-PA
BP > 185/110
BG < 50
(basically lots of bleeding things or past surgeries)
if stroke/head trauma or MI in past 3 months
if on warfarin and INR > 1.7
Can do t-PA up to 4.5 hours after symptom onset IF the patient has NONE of the following
- Age ______
- Hx of ______
- Any recent _______
- NIHSS score > ____
Age: > 80
Hx of previous stroke or diabetes
Any recent anticoag use
NIHSS score > 25
ADEs of Alteplase
Bleeding and _________
Cerebral edema!
Dosing for t-PA
- 09 mg/kg - IV bolus over 1 minute
- 81 mg/kg - IV infusion over 60 mins
MAX of 90 mg (aka if over 100 kg there only getting 90mg total)
Ischemic Stroke: Acute Blood Pressure Goals depend on ______
if t-PA was given or not
Acute BP goal if t-PA IS NOT given:
BP < 220/120 mmHg within first 24 hours
Acute BP goal if t-PA IS given:
BP < 180/105 mmHg within first 24 hours
Drug options for decreasing BP
- Nicardipine
- Labetalol
- Sodium Nitroprusside
who gets aspirin post stroke?
ALL ISCHEMIC stroke pts (def not hemorrhagic stroke pts)
when should patients start aspirin post stroke?
if given t-PA: start 24 hours after t-PA
if NO t-PA given then immediately!
which ischemic stroke patient is NOT kept on aspirin forever/are switched to another med after a week of aspirin?
CARDIOEMBOLIC - they get switched to an anticoag
should an anticoag be given for managing acute embolic strokes?
NO anti-platelet (aspirin) for at least a week first (can increase bleeding complications)
options for managing hemorrhagic stroke: \_\_\_\_\_\_\_\_ reversing \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_ anti-\_\_\_\_\_\_\_\_\_\_\_ Prevention of \_\_\_\_\_\_\_\_\_ Anti\_\_\_\_\_\_\_\_\_\_\_
supportive care reversing causative meds surgery ant-hypertensives Prevention of cerebral vasospasm Anticonvulsants
Ischemic or Hemorrhagic stroke: which one is more likely to have vasospasm complication
Hemorrhagic (try to prevent by using Nimodipine)
Highest risk for Vasospasm is __________ days after stroke
4- 21
how to prevent vasospasm complication with hemorrhagic stroke
use Nimodipine
BP goals for Hemorrhagic Stroke:
first 24 hrs: < 180/110
After first 24 hrs in hospital: < 160/90
(normal goal after hospital aka < 140/90)
Ischemic or Hemorrhagic stroke?
which one has risk of seizure after the stroke
hemorrhagic
How to manage seizure risk with hemorrhagic strokes?
nothing really… it is NOT recommended to give anticonvulsants as prophylaxis
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Antidepressants
both
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Antiplatelet
Ischemic (esp. artheroscelorsis)
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Anticoagulant
Ischemic (esp. cardioembolic)
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Anithypertensive
both
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Rehabilitation
both
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Cholesterol Reducing Agetns
Ischemic (esp. atherosclerosis)
For Post-Stroke Management:
Ischemic, Hemorrhagic, or both?
Risk factor reduction
both
POST-STROKE MANAGEMENT:
which drug options are first line for secondary prevention for non-embolic ischemic stroke
since NON-EMBOLIC
Aspirin or Dipyradimole (or combo of the two)
POST-STROKE MANAGEMENT:
which drug options are second line for secondary prevention for non-embolic ischemic stroke
Clopidogrel
or
Clopidogrel + Aspirin
what is the combo drug of dipyridamole and aspirin called
Aggrenox
POST-STROKE MANAGEMENT:
which drug options are NOT recommended for secondary prevention for non-embolic ischemic stroke
Ticagrelor or Prasugrel
POST-STROKE MANAGEMENT:
which drug options are first line for secondary prevention for embolic ischemic stroke
any DOAC or Warfarin is cool to use (START 7+ days AFTER stroke also discontinue aspirin before starting anticoag)
What are some prophylactic antidepressants to use in stroke pts
SSRIs: Sertraline; Fluoxetine; Escitalopram/Citalopraim
What are some prophylactic antidepressants to avoid in stroke pts
Paroxetine (an SSRI w/more anticholinergic side effects)
TCAs (w/more anticholinergic side effects)
what to start an antidepressant with a stoke pt
like almost immediately because of the delayed onset of action
