STROKE, TIA Flashcards
TIA formation
1) Blocked artery
2) Ischemic stroke occurs when blood clot blocks blood flow in artery within the brain
i) Narrowing of carotid arteries
ii) Embolism of clot
penumbra
brain tissue still salvageable
thrombolyse in 3-4.5hr
TOAST criteria in Acute stroke tx
1) Stroke of other determined causes
2) Small-vessel disease (penetrating artery disease PAD)
3) Cardioembolic stroke –> AF
3) Large artery atherosclerosis
mNIHSS scale to evaluate effect of acute cerebral infarct on brain functions
- lvl of consciousness
- gaze
- visual field
- left arm
- right arm
- left leg
- right leg
- sensory
- language
- neglect
mNIHSS is used to ___
use of sx to find out location of obstruction
eligibility of rTPA
minor stroke: NIHSS 0-3
TIA use ABCD2
estimate risk of ischemic stroke in first 3 days after TIA
1) age =/> 60 yo
1) BP =/> 140/90
clinical features:
2) unilateral weakness
1) isolated speech distubrances
2) =/> 60mins
1) 10-59mins
1) DM present
ABCD2 score
high risk TIA: =/>4
new onset AIS
(not on antithrombotic therapy)
rTPA eligibility?
y: start SAPT (after 24h - 48h)
n:
1) minor stroke, high risk TIA = DAPT asap (21d)
2) not minor = start SAPT asap
stroke mechanism
find out cause of stroke
- MRI
- 24hr Holter, ECG: find if 1* cardioembolism (AF)
- TTE: if got any other clots in heart, EF, valvular heart disease
- Ultrasound carotids: atherosclerosis
- Lipid panel, TFTs, HbA1c, blood test
CARDIOEMBOLIC (20%)
stop antiplt
if AFib: start DOAC (SPAF)
non cardioembolic
severe major ICAS
- DAPT 90d (clopi)
- lifelong SAPT
non severe, major
- lifelong SAPT
ICAS
itracranial arterial stenosis
cerebral artery
- anterior, middle, posterior
rTPA eligibility (inclusion & exclusioN)
inclusion
- acute ischemic stroke
- within 4.5hr of onset
- CT scan consistent with acute ischemic stroke
exclusion
-no haemorrhage (GI, brain)
- stroke, head trauma < 3mnths
- seizure onset of stroke
- major surgery < 14d
rTPA dose
can use tenecteplase also, streptokinase, urokinase
within 3hr/ 4.5hr
0.9mg/kg (max 90mg)
aspirin dose
Load 300mg
(no load if currently on aspirin)
Follow: 100mg OM (lifelong)
Can be mono
aspirin feature
** DAPT unless allergic (densitisation carried out, NSAID cross-allergy)
Not for 1* prevention of ASCVD unless atheroscleorsis
clopidogrel dose
Load 300mg (6h onset) or 600mg (2h onset)
Follow: 75mg OM
Can be mon
clopidogrel feature
CYP2C19 LOF (2* 3*)
- incr risk fo CV, CB events (MACCE)
- as less clopido effect to protec
- CCS for 6mnths
ticagrelor dose
Load: 180mg
Follow: 90mg BD ~ 12mn
Can be mono
tica feature
- Not subjected to CYP2C19 polymorphism. Preferred in most ACS indication (12mnth –> MI)
- Higher bleeding risk
- high adenosine (bradycardia, dyspnea)
Genotype guided selection of P2Y12i (ACS + PCI pts) for net benefit
dipyridamole dose
(PO, antiplt)
25mg - 150mg TDS
Combi with aspirin
* Stroke when even on aspirin
2* prevention
dipyridamole feature
Neuro: 2* post AIS
- immediated release TDS, tolerability issues need push to incr dose
- SR not avail in SG
IV: imaging agent in cardiology
when is DAPT administered
within 24h - 48h (per stroke etiology)
when is anticoag administered?
per indication, usually not within 24hr of rTPA
for cardioembolic
FOR vte PROPHYLAXIS
stroke VTE prophylaxis
LMWH within 48h. after 24h of rTPA
- due to immobile state
- monitor bleedign risk within 72hr
40mg OD until ambulatory
goals of therapy
1) thrombolytic agents: reperfusion
2) anticoag: 2* prevention of cardioembolic stroke
2* AF
3) antiplt: DAPT (21d or 90d)
tx of CV risk factors: 2nd prevention ASCVD – HTN, Hyperlipidemia, AF, DM
adherence! (lifelong SAPT, LT DAPT)
HTN control with
ACEi
CCB
thiazide diuretic
high intensity statins
atorvastatin 40-80mg
rosuvastatin 20-40mg
add in ezetimbe if LDL > 1.8mmol/L
