TEST #3 Hon Stroke Flashcards
Facts About Stroke
- Third leading cause of death in U.S.
- Leading cause of long-term disability in U.S.
- Annual health care cost >$40 billion.
- Annually, 90,000 women & 60,000 men die, 2/3 within 90 days of their stroke.
- Among survivors, the majority will have residual impairment and disability.
- Approximately 25% of survivors WILL HAVE ANOTHER STROKE. Important cause of death and disability in women, including both Pregnancy and the Postpartum period.
- Under age 45 yr., more women die from stroke than from Myocardial Infarction.
Subtype of Stroke
1) HEMORRHAGIC STROKE: 20% of cases
- Intracerebral hemorrhage (cortical vs. subcortical)
- Subarachnoid hemorrhage
2) ISCHEMIC STROKE - 80% of cases
- Large artery atherosclerosis with thromboembolism
- Small vessel (lacunar) disease
- Cardioembolism
- Nonatherosclerotic Vasculopathies
- Hypercoagulable states
Risk Factors for Stroke Part 1
A) INCREASING AGE
B) PREVIOUS TIA or Stroke
C) ATHEROSCLEROSIS
- HTN
- Smoking
- Diabetes Mellitus
- Hyperlipidemia
D) CARDIAC DISORDERS
- Valvular Heart Disease
a) Dysfunctional or Prosthetic Valve - Cardiac Dysrhythmia
a) e.g.Atrial Fibrillation - Mural Thrombus
- Endocarditis
- Atrial Myxoma
- Interatrial septal abnormalities
Risk Factors for Stroke Part 2
A) DRUG ABUSE
- IVDA, Cocaine, Amphetamines
B) ORAL CONTRACEPTIVES
C) PREGNANCY/ POSTPARTUM PERIOD
D) FIBROMUSCULAR DYSPLASIA
E) HYPERCOAGUABLE STATES - Thrombocytosis - Polycythemia - Sickle Cell Disease - Leukocytosis - Protein C, Protein S deficiency - Homocysteine - Anticardiolipin / Antiphospholipid antibodies
F) INFLAMMATORY DISORDERS
- Giant Cell Arteritis
- SLE
- Polyarteritis Nodosa
- Granulomatous Angiitis
- Syphilitic Arteritis
- AIDS
G) MIGRAINE!!!
Symptoms of Stroke
1) LEFT HEMISPHERE:
- Aphasia, right sided sensory symptoms, right sided motor symptoms, right visual field cut
2) RIGHT HEMISPHERE:
- Left hemineglect, left sided sensory symptoms, left sided motor symptoms, left visual field cut,
3) CEREBELLAR:
- Ipsilateral ataxia, vertigo, nystagmus
4) BRAINSTEM:
- Cranial nerve findings with contralateral hemisensory or hemimotor symptoms, vertigo
General Management of Stroke
- Primary Prevention
- Management of the acute stroke itself
a) (major area of change) - Prevention or control of medical complications
a) Med .Complications account for 50% of deaths attributable to stroke (e.g.pneumonia,DVT, PE, UTI, decubitus ulcers). - Rehabilitation
- Prevention of recurrent stroke
Emergency Diagnosis and Treatment
A) ABC’s - Airway, Breathing, & Circulation.
B) BP, pulse, cardiac monitor, EKG, O2 saturation
- Acute HTN is common in acute ischemic stroke and in most cases should NOT be treated.
- The area of infarction may have lost autoregulatory function, so that “normal” BP may be relatively hypotensive in the brain.
C) IV Access
- All stroke patients need to have IV access.
- IVF’s should NOT include glucose as hyperglycemia is associated with worse
neurologic outcomes!!!!!!!! - If tPA is a consideration, two IV access sites will be needed to eliminate venipuncture after infusion.
D) Neurologic examination and rapid transport to CT scan.
E) Labs:
- CBC c diff
- PT, PTT
- full chemistry panel & fingerstick glucose
- UA
- CXR
NIH Stroke Scale
A) Important if tPA or intra-arterial intervention is a consideration.
B) Score ranges from 0 (normal) to 42 (coma) and can be used to predict hemorrhagic conversion:
- Score 20 = 17%RISK OF HEMORRHAGE!!!!!!!
Summary of Evaluation and Treatment of Acute Stroke
- Maintain airway, breathing, circulation.
- Elevate HOB to 30 degrees!!!!!!!!!!!!!!!!!
- O2 @ 2 liters per NC.
- Obtain vital signs and establish IV with NS
- Obtain labs: CBC, PT, PTT, Chem. profile
- EKG
- Obtain patient weight.
- Try to identify cause and treat fever if present.
- OBTAIN HISTORY:
a) When was last time pt. known to be w/o symptoms?
b) Did head trauma or seizure occur at onset symptoms?
c) Is patient on warfarin/heparin?
d) Does pt. have symptoms suggestive of M.I.?
e) Does pt. have symptoms suggestive of intracranial hemorrhage?
CT Findings
1) CEREBRAL INFARCTION:
- If patient meets all tPA criteria consider administering tPA if absolutely sure of time deficits
began.
2) NORMAL:
- Consider another cause: seizure, migraine, hypoglycemia, etc.
- If history most consistent with ischemia, consider tPA or other therapies (ASA, Aggrenox,
Ticlid, Plavix, etc.)
IV THrombolytic Therapy: t-PA
- The results of parts 1 and 2 of the NINDS rt-PA Stroke Study support the use of t-PA for the treatment of acute ischemic stroke in patients who meet the eligibility requirements if treatment is initiated within 3 hours of the onset of symptoms (? better within 1 1⁄2 hr).
- Of the patients treated with t-PA, 31-50% had complete or near- complete recovery at 3 months as compared with 20-38% of patients given placebo.
IV t-PA
Eligibility Criteria
- Age >= 18 yr.
- Diagnosis of ischemic stroke with clinically apparent neurological deficits
- No stroke or head trauma in preceding 3 mo.
- No major surgery in preceding 14 days
- No h/o intracranial hemorrhage
- No rapidly resolving symptoms or only minor symptoms of stroke
- No symptoms suggestive of SAH
- No GI or GU hemorrhage in preceding 21 days
- No arterial puncture at a non-compressible site in preceding 7 days
- No seizure at onset of symptoms
- PT= 100,000mm3
- Blood glucose > 50 mg/dl
- SBP
Treatment of Acute Ischemic Stroke with IV t-PA
- Infuse t-PA at a dose of 0.9 mg/kg (max. 90 mg) over a 60 min. period with the first 10% of the dose given as a bolus over a 1 min. period.
- Perform neuro. assessments and check BP q 15 min. during infusion, q 30 min. for 6 hr. after, and then q 60 min. for the next 16 hr. (in ICU or
stroke unit) - If severe HA, acute HTN, or N/V occur, stop infusion and obtain an emergent CT head.
- If SBP >=180 or DBP>=105 mm Hg, check BP more frequently and give anti-HTN drugs as needed to maintain BP at below those levels. (see table for BP management from AHA)
What about Anticoagulation?
A) ANTICOAGULATION with HEPARIN is sometimes used in an effort to:
- Prevent or limit progression in patients with acute atherothrombotic infarction,
- Or to prevent recurrent embolism in patients with cardioembolic stroke.
- This is an area of great controversy!
B) Early studies of heparin, many performed before the advent of CT, suggested a 50% reduction in the chance of neurologic worsening,
particularly for subcategories of:
- TIA
- Stroke-in-progression.
***** However, all of these early studies have been found to have serious methodological flaws.
- *** Regarding the treatment of acute ischemic stroke and use of Heparin, there is no consensus re:
- Indications
- Optimum level of anticoagulation
- Use of a loading bolus
- Duration of therapy.
C) The American Heart Association Guidelines for the Management of
Acute Ischemic Stroke:
- Strongly recommends the prophylactic administration of heparin or low-molecular-weight Heparin or Heparinoids to prevent DVT in immobilized patients with acute stroke when there is no contraindication to antithrombotic drugs.
D) Beyond this, they COULD NOT make further recommendations for heparin and state:
- “Until more data are available, the use of Heparin remains a matter of PREFERENCE of the treating physician. It should be understood that the use of heparin (or the lack of its administration) may not alter the outcome of a patient with acute ischemic stroke.”
Other Agents
- Aspirin (?dose)
- Aggrenox
- Ticlid
- Plavix
- Persantine
- Warfarin
- ?Low Molecular wt. heparin
- Dagibatran Etexilate (Pradaxa) - Riveroxaban (Xarelto)
- Apixaban (Eliquis)
