Stroke - Reynolds

Question 1

Strokes:

• affects > ____ persons per year
• causes ____ deaths per year
• ____th leading cause of death
• leading cause of long-term ____
• costs > $70 billion per year

Answer 1

• affects > 800,000 persons per year
• causes 200,000 deaths per year

•5th leading cause of death

• leading cause of long-term disability
• costs > $70 billion per year

Question 2

Stroke Syndrome:

• Sudden acute neurological deficit
• Stroke have ___ etiologies. They can be: ___ or ____ infarcts.
• Infarction is death of ___, ___ and ___ due to ischemia
• Hemorrhage occurs when there is bleeding into the brain ____ or potential ___ space.
• ___ ____ occurs when there is bleeding into an area of ischemic infarction

Answer 2

Stroke Syndrome:

• Sudden acute neurological deficit
• Stroke have vascular etiologies. They can be: hemorrhagic or ischemic infarcts.
• Infarction is death of glial, neuronal and endothelium due to ischemia
• Hemorrhage occurs when there is bleeding into the brain parenchymal or potential intracranial space
• Hemmorhagic infarct occurs when there is bleeding into an area of ischemic infarction

Question 3

As blood flow goes down, you can progress to ___ ____ and then neuronal cell death.

Answer 3

As blood flow goes down, you can progress to electrical failure and then neuronal cell death.

Question 4

Types of strokes:

1. ____ stroke - where you have an occluded artery and braincells will die (___%) downstream from that occlusion.
2. ___ stroke:
   - ____ (intraparenchymal - __%) - bleeding into the brain
   - ____ - __% - bleeding around the brain

Answer 4

Types of strokes:

1. Ischemic stroke - where you have an occluded artery and braincells will die (85%) downstream from that occlusion.
2. Hemmorhagic stroke:
   - Intracerebral (intraparenchymal - 10%) - bleeding into the brain

- Subarachnoid - 5% - bleeding around the brain

Question 5

Answer 5

Acute infarct (blocked blood vessel) on MRI and Pathology

Question 6

Answer 6

Intracerebral Hemorrhage
Burst blood vessel

Question 7

Answer 7

Subarachnoid hemorrhage
Bleeding around the brain, usually from an aneurysm rupture

Question 8

TIA:

• ____ (low-blood-flow) stroke without ___ ___
• “___” of the brain
• <___ h by definition, but usually ___-___ min
• important warning of impending stroke. ___% of people who have TIA’s will have a full-blown stroke within __ months. Another 5% of people who have TIA’s will have a full-blown stroke within ___ hours.
• prompt evaluation urgent to prevent future stroke–find out the cause!

Answer 8

TIA:

• ischemic (low-blood-flow) stroke without permanent damage
• “angina” of the brain
• <24 h by definition, but usually 2-20 min
• important warning of impending stroke. 5% of people who have TIA’s will have a full-blown stroke within 3 months. Another 5% of people who have TIA’s will have a full-blown stroke within 48 hours.
• prompt evaluation urgent to prevent future stroke–find out the cause!

Question 9

Stroke Symptoms: All symptoms occur suddenly

• ___ess or __ess, esp. 1 side of body
• difficulty speaking or understanding speech
• ____ loss in one or both eyes
• severe, unusual ____
• dizziness, if associated with another symptom

Answer 9

Stroke Symptoms: All symptoms occur suddenly

•weakness or numbness, esp. 1 side of body

• difficulty speaking or understanding speech
• visual loss in one or both eyes
• severe, unusual headache
• dizziness, if associated with another symptom

And Now, I VILL PLAY “D SHWVN

Question 10

Hemmorhage vs. Ischemic Stroke

• Both present with ___, ___ deficit
• Supporting evidence for hemorrhage
• Severe ____ at onset (especially worst H/A of patient’s life with ___ ___ ____)
• younger age with h/o of ___
• Greater than expected ____ (mental dullness) with hemispheric stroke than usually seen in patients with ischemic infarcts
• CANNOT make definitive dx clinically
• *** Non-contrast head CT ***

Answer 10

Hemmorhage vs. Ischemic Stroke

• Both present with sudden, acute deficit
• Supporting evidence for hemorrhage
• severe H/A at onset (especially worst H/A of patient’s life with subarachnoid hemmorhage)
• younger age with history of of hypertension.
• Greater than expected obtundation with hemispheric stroke than usually seen in patients with ischemic infarcts
• CANNOT make definitive dx clinically
• *** Non-contrast head CT ***

Question 11

What is this?

Answer 11

right thalamic hemmorrhage

Question 12

Answer 12

Subarachnoid -aneurysm ruptured

Question 13

Stroke Risk Factors

•Medical

HHH. T. DOS

•Lifestyle

MS. DD. AS

Answer 13

Stroke Risk Factors

•Medical

• Hypertension
• Heart disease, especially a-fib
• Hyperlipidemia,
• Prior stroke or TIA
• Diabetes
• Obesity
• Sickle cell disease

•Lifestyle

• Marijuana use
• Smoking
• Diet
• Drugs (legal and illegal)
• Alcohol use - heavy
• Sedentary lifestyle

Question 14

Ischemic Stroke Causes:

• _____ 45%
• _____ 20%
• ____embolism 20% (from a-fib)
• _____ - often iatrogenic (relating to illness caused by medical examination or treatment)
• _____ states - Due to protein __ and __ antibodies that float around (remember, these proteins are anti-coagulants, so if you haev anti-bodies against them, then you will not be able to get rid of clots), as well as anti____ antibodies (a-PL)

Artery diseases other than atherosclerosis:

• •Dissections, ___ (usually in younger people)

Answer 14

Ischemic Stroke Causes:

• Atherocleoris 45%
• SAD (small artery disease) 20%

•Cardioembolism 20% (a-fib)

• hypoperfusion - often iatrogenic (relating to illness caused by medical examination or treatment)
• hypercoagulation states - Protein C, S, antiphospholipid antibodies (a-PL)

Artery diseases other than atherosclerosis:-

•Dissections, vasculitis (usually in younger people)

Question 15

_Major Causes of
Hemorrhagic (Bleeding) Strokes:_

•Non-traumatic intracerebral hemorrhage

• bleeding into the brain itself
• usually due to longstanding high __ __ and small artery ___

•Non-traumatic subarachnoid hemorrhage

• bleeding into __ space
• usually due to a ruptured __ __

Answer 15

Major Causes of
Hemorrhagic (Bleeding) Strokes

•Non-traumatic intracerebral hemorrhage

• bleeding into the brain itself
• usually due to longstanding high blood pressure and small artery rupture

•Non-traumatic subarachnoid hemorrhage

• bleeding into subarachnoid space
• usually due to a ruptured berry aneurysm

Question 16

Defending Against Brain Attack

Primary prevention

• identify and control/treat risk factors
• emergency action
• know warning signs (symptoms), call 911
• HTN, DM, hyper___, smoking, __ __ disease, carotid stenosis, obesity

Patient education for life-style changes:

• ____ cessation
• Medication adherence
• Diet/exercise
• Stop excessive ___ use and sympathomimetic drug use

Secondary prevention

• identify ___ of stroke
• take appropriate action (medicine, surgery, etc.) and initiate appropriate anti-thrombotic therapy
• Identify and treat all risk factors

Answer 16

Defending Against Brain Attack

Primary prevention

• identify and control/treat risk factors
• emergency action
• know warning signs (symptoms), call 911
• HTN, DM, hyperlipidemia, smoking, sickle cell disease, carotid stenosis, obesity

Patient education for life-style changes:

• smoking cessation
• Medication adherence
• Diet/exercise
• Stop excessive drug use and sympathomimetic drug use

Secondary prevention

• identify cause of stroke
• take appropriate action (medicine, surgery, etc.) and initiate appropriate anti-thrombotic therapy
• Identify and treat all risk factors

Question 17

T-Pa Emergency Stroke Treatment

• _____ using t-PA available for patients with ___ stroke
• tPA does NOT save ____
• t-PA decreases risk of ____ if given within ___ hours of ___ onset
• Only FDA approved for < 3 but standard of care + < 4.5 with some additional exclusions
• t-PA may cause dangerous ___ if given after the time window to a person with a very large ___

Answer 17

T-Pa Emergency Stroke Treatment

•Thrombolysis using t-PA available for patients with ischemic stroke

• tPA does NOT save lives
• t-PA decreases risk of disability if given within 4.5 hours of stroke onset
• Only FDA approved for < 3 but standard of care + < 4.5 with some additional exclusions
• t-PA may cause dangerous bleeding if given after the time window to a person with a very large stroke

Question 18

How does t-Pa work?

_____ is zone of ____ ischemia around the core of an irreversible infarction

The ____ is salvageable within the first few hours after ischemic stroke onset

Penumbra is damaged by:

• ____ perfusion
• Hyper____
• Fever
• Seizure

Answer 18

How does t-pa work?

Penumbra is zone of reversible ischemia around the core of an irreversible infarction

Penumbra is salvageable within first few hours after ischemic stroke onset

Penumbra is damaged by:

• Hypoperfusion

• Hyperglycemia

• Fever
• Seizure

Question 19

TREATMENT OF INFARCTION

Hyperacute Therapy

• The rationale for hyperacute therapy is preservation of viable but nonfunctional tissue in the ___
• Therapeutic approaches include restoration of blood __, decreased metabolic demands or prevention of 2º ischemic changes (neuroprotective agents) and inhibitors of the post-ischemic inflammatory response
• ____ therapy has been shown to be effective in humans in Phase 3 trials
• ___ is the only FDA approved acute stroke drug therapy
• ____ therapy with thrombectomy and clot removal/disruption has also been proven effective

Answer 19

TREATMENT OF INFARCTION

Hyperacute Therapy

• The rationale for hyperacute therapy is preservation of viable but nonfunctional tissue in the penumbra
• Therapeutic approaches include restoration of blood flow, decreased metabolic demands or prevention of 2º ischemic changes (neuroprotective agents) and inhibitors of the post-ischemic inflammatory response

•Thrombolytic therapy has been shown to be effective in humans in Phase 3 trials

•T-Pa is the only FDA approved acute stroke drug therapy

•Endovascular therapy with thrombectomy and clot removal/disruption has also been proven effective

Question 20

Thrombus Formation and how T-Pa works

• Fibrinogen, in the presence of ____, creates Fibrin Strands. Fibrinogen is a soluble protein present in blood plasma, from which fibrin is produced by the action of the enzyme ___
• __ __ and ___ adhere to the fibrin strands
• Activated factor ___ stabilizes the clot

To break up the clot:

• ____, in the presence of plasminogen activators, form plasmin
• Plasminogen activators are upregulated by binding to ____, making their activity ‘___-specific’
• Plasmin degrades ___. This is how __ works…*

Answer 20

Thrombus Formation

•Fibrinogen, in the presence of THROMBIN, creates Fibrin Strands. Fibrinogen is a soluble protein present in blood plasma, from which fibrin is produced by the action of the enzyme thrombin.

•Red cells and platelets adhere to the fibrin strands

•Activated Factor XII stabilizes the clot

To break up the clot

Plasminogen in the presence of plasminogen activators, form plasmin

• Plasminogen activators are upregulated by binding to fibrin, making their activity ‘clot-specific’
• Plasmin degrades fibrin. This is how tPA works…*

Question 21

Only give T-pa:

Within less than ___ hours (when the last time the person was acting normal)

Pressure must be less than ___/___

•Don’t give T-Pa to people who are:

• Already _____
• Have bleeding contraindications
• Seizures or trauma (T-Pa can enhance the N-methyl-D-aspartate receptor also known as the NMDA receptor, a glutamate receptor, which can induce seizures).
• Blood sugar is ___. Hypoglycemia can cause focal neurologic deficits and thereby masquerade as a true ischemic stroke. It would be a shame to subject someone to the risk of intracranial hemorrhage from tPA if all they needed was dextrose.
• Recent ____ or arterial stick in non-compressible site

Answer 21

• T Time < 4.5 hours
• P Pressure < 185/110

•Don’t give T-Pa to people who are:

• Already anticoagulated
• Bleeding contraindications
• Seizure or trauma
• Blood sugar low. Blood sugar is ___. Hypoglycemia can cause focal neurologic deficits and thereby masquerade as a true ischemic stroke. It would be a shame to subject someone to the risk of intracranial hemorrhage from tPA if all they needed was dextrose.
• Recent surgery or arterial stick in non-compressible site

Question 22

Endovascular Therapy:

Good for ___, ___ artery occlusions

• Usually within ___ hours of onset to start procedure
• Clot ___ or mechanical ____ works best
• Stent retriever devices work the best

Answer 22

Endovascular Therapy:

• Good for proximal, large artery occlusions
• Usually within 6 hours of onset to start procedure
• Clot retrieval or mechanical disruption works best
• Stent retriever devices work the best

Question 23

Acute Stroke Treatment:

• The ONLY acute stroke treatments are ___ and ___ ___
• There is NO role for ____ in the treatment of acute ischemic stroke from an arterial lesion
• Remember that heparin is an ___ and not a ___
• Heparin will not ___ a clot that is already there
• Heparin will increase ____ complications

Heparin is ___ the answer on a test if the question is referring to treatment of an ischemic stroke of arterial origin. We sometimes use heparin to try to ____ another stroke in an acute setting.

Heparin is often used acutely to treat a stroke due to a venous thrombosis such as a clot in a brain sinus. This is a “deep” clot analogous to a DVT anywhere else in the body and the treatment is anticoagulation to allow the body to deal with the clot and prevent clot propagation.

Answer 23

Acute Stroke Treatment:

• The ONLY acute stroke treatments are tPA and endovascular therapy
• There is NO role for heparin (an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels). in the treatment of acute ischemic stroke from an arterial lesion
• Remember that heparin is an anticoagulant and not a thrombolytic.
• Heparin will not dissolve a clot that is already there
• Heparin will increase bleeding complications

Heparin is NEVER the answer on a test if the question is referring to treatment of an ischemic stroke of arterial origin. We sometimes use heparin to try to PREVENT another stroke in an acute setting.

Heparin is often used acutely to treat a stroke due to a venous thrombosis such as a clot in a brain sinus. This is a “deep” clot analogous to a DVT anywhere else in the body and the treatment is anticoagulation to allow the body to deal with the clot and prevent clot propagation.

Question 24

All ischemic stroke patients likely benefit from ___ therapy regardless of their cholesterol profile

Answer 24

All ischemic stroke patients likely benefit from statin therapy regardless of their cholesterol profile

Question 25

Secondary Prevention: Anti-thrombotic therapies:

1. Anticoagulants:

• ___ (depletes Vit K dependent clotting factors [__, __, __, __ and __ __
• ____ (direct thrombin inhibitor)

___, ___ (Oral Factor Xa inhibitor, which prevents prothrombin conversion to thrombin)

2. Antiplatelet agents:

DAC TAC

Answer 25

Secondary Prevention: Anti-thrombotic therapies:

1. Anticoagulants:

•Warfarin (depletes Vit K dependent clotting factors [II, VII, IX and X and Prot C)

•Dabigatran (direct thrombin inhibitor)

Apixaban, rivaroxaban (Oral Factor Xa inhibitor)

A picture on the river warf with da biggie

2. Antiplatelet agents:

• Aspirin
• Ticlopidine (Ticlid®) and Clopidogrel (Plavix®)
• Thienopyridines
• Dipyridamole (used in combination with asa as Aggrenox ®)
• Cilostazole (Pletal®)

A silly deer tick in my ass made me clap

DACC TT

Question 26

When do you choose an anti-coagulation over an anti-platelet?

If you think the heart caused the stroke, use an anti-____.

When do you use an anti-platelet?

Answer 26

When do you choose an anti-coagulation over an anti-platelet?

If you think the heart caused the stroke, use an anti-coagulant.

• Cardioembolic source
• Atrial fibrillation
• Mechanical valves
• Severe cardiomyopathy
• EF < 30% causes the ventricle to become a source of thrombus
• Patent foramen ovale (PFO) and atrial septal aneurysm (ASA)
• Hypercoagulable state (such as protein S deficiency)
• Venous infarction (i.e. sagittal sinus thrombosis)

When do you use an anti-platelet?

• Atherosclerotic disease
• Small artery disease
• Any ischemic stroke patient without an identified need for anticoagulation

There are two main types of blood thinners. Anticoagulants, such as heparin or warfarin (also called Coumadin), work on chemical reactions in your body to lengthen the time it takes to form a blood clot. Antiplatelet drugs, such as aspirin, prevent blood cells called platelets from clumping together to form a clot.

Question 27

Antiplatelet agents are recommended for non-____ strokes, which constitute the ____ of ischemic strokes, as well as for long-term prevention after ___
endarterectomy. A cardioembolic stroke occurs when the heart pumps unwanted materials into the brain circulation, resulting in the occlusion of a brain blood vessel and damage to the brain tissue.

Anticoagulation, usually with ___, is the recommended therapy after _____
stroke.

Anticoagulants are indicated after most types of ____ stroke and for prevention of first stroke in patients with atrial fibrillation.

Antiplatelet agents are recommended for ____stroke prevention in all other situations, including after __ __ (widening of artery using a stent)

Answer 27

Antiplatelet agents are recommended for non-cardioembolic strokes, which constitute the majority of ischemic strokes, as well as for long-term prevention after carotid
endarterectomy.

A cardioembolic stroke occurs when the heart pumps unwanted materials into the brain circulation, resulting in the occlusion of a brain blood vessel and damage to the brain tissue.

Anticoagulation, usually with warfarin, is the recommended therapy after cardioembolic
stroke.

Anticoagulants are indicated after most types of cardioembolic stroke and for prevention of first stroke in patients with atrial fibrillation.(9) Antiplatelet agents are recommended for reucurrent stroke prevention in all other situations, including after carotid endarterectomy (widening of artery using a stent)

Question 28

How to Fix Carotid Artery Stenosis

• Carotid ___ (CEA)
• Carotid Artery ___ (CAS)
• Both are effective for symptomatic, high-grade __ __
• 50-99% stenosis
• Symptomatic means recent __ or __
• *** Cannot fix a complete___

Answer 28

How to Fix Carotid Artery Stenosis

• Carotid Endarterectomy (CEA)
• Carotid Artery Stenting (CAS)
• Both are effective for symptomatic, high-grade carotid stenosis
• 50-99% stenosis
• Symptomatic means recent TIA or stroke
• *** Cannot fix a complete occlusion

Question 29

Stroke Treatment Algorithm

•Patient presents with __ __ stroke.

Algorithm for stroke treatment

• Determine eligibility for treatment with ___ and/or ____ therapy and treat if eligible
• Acutely, all stroke patients need some form of ____ therapy with at least ___
• *note that no antithrombotics for 24 hours if patient receives tPA
• Early ____ therapy
• DVT ___

Answer 29

Algorithm for stroke treatment

• Patient presents with acute ischemic stroke
• Determine eligibility for treatment with tPA and/or endovascular therapy and treat if eligible
• Acutely, all stroke patients need some form of antithrombotic therapy with at least aspirin
• *note that no antithrombotics for 24 hours if patient receives tPA
• Early statin therapy
• DVT prophylaxis

Question 30

For:

Cardioembolism

Hypercoagulable patients

Venous Infarcts

What type of medication would you use to prevent strokes?

For:

Large or small vessel atherosclerosis

What type of medication would you use for these?

Answer 30

Cardioembolic

Hypercoagulable

Venous Infarct

You should use Warfarin or anti-thrombotics. This slows down the coagulation mechanism - prevents coagulation cascade. Anti-coagulants!

For:

Large or small vessel atherosclerosis

Use an ANTI-PLATELET

Question 31

Answer 31