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Clinical 2 (Sam) > 7 - Stroke > Flashcards

7 - Stroke Flashcards

1
Q

What is a stroke?

A

abrupt onset focal neurologic deficit that lasts > 24 hours and is of presumed vascular origin

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2
Q

87% of strokes are ______, caused by interruption of blood flow to the brain due to a clot

A

ischemic

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3
Q

13% of strokes are _______, caused by uncontrolled bleeding in the brain

A

hemorrhagic

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4
Q

What are the 3 types of ischemic stroke?

A
  • thrombotic
  • embolic
  • transiet ischemic attack (TIA)
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5
Q

Describe a thrombotic ischemic stroke

A

thrombus formation inside an artery in the brain (i.e. atherosclerosis of cerebral vasculature)

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6
Q

Describe an embolic stroke

A

emboli from intra or extra cranial arteries

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7
Q

Describe a carotid stenosis

A

Atherosclerotic plaque rupture -> thrombus formation -> local occlusion or dislodge as emboli and causes downstream cerebral vessel occlusion

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8
Q

Describe a cariogenic embolism

A
  • Secondary to valvular heart disease, or non-valvular atrial fibrillation
  • Atrial blood stasis -> emboli -> occlusion of cerebral circulation
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9
Q

What is a Transient Ischemic Attack (TIA) ?

A

Temporary focal neurologic deficit lasting less than 24 hrs (typically < 30 min as a result of diminished or absent blood flow)

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10
Q

What does a TIA commonly result from?

A

small clots breaking away from larger, distant clots

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11
Q

T or F: TIA has no residual neurologic deficit

A

True

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12
Q

Describe a hemorrhagic stroke

A
  • Escape of blood from cerebral vasculature into surrounding brain structure
  • Initial neurologic deficit attributable to direct irritant effects of blood in contact with brain tissue
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13
Q

What are modifiable risk factors for stroke?

A
  • hypertension
  • smoking
  • dyslipidemia
  • diabetes
  • heart disorders (ex. atrial fibrillation, infective endocarditis)
  • hypercoagulability
  • lifestyle: obesity, physical inactivity, diet
  • psychosocial stress (ex. depression)
  • intracranial aneurysms
  • alcohol use, carotid stenosis
  • drugs
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14
Q

What are non-modifiable risk factors for stroke?

A
  • age (risk doubles each decade older than 55 yrs)
  • male sex
  • family history
  • prior stroke
  • race
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15
Q

Describe the clinical presentation of a stroke

A

One sided weakness: sudden loss of strength or sudden numbness in the face, arm or leg

Trouble speaking: sudden difficulty speaking or understanding or sudden confusion

Vision problems: trouble seeing in one or both eyes, photophobia

Headache: sudden severe and unusual headache with no explainable cause

Dizziness: sudden loss of balance, vertigo, nausea/vomiting

Altered level of consciousness

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16
Q

In ACS, time = muscle.

In stroke, time = ?

A

brain cells

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17
Q

What are the warning signs of a stroke?

A

Face (is it drooping?)
Arms (can you raise both?)
Speech (is it slurred or jumbled?)
Time (to call 911 right away)

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18
Q

Acute phase of a stroke?

A

0-7 days

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19
Q

Hyperacute phase of a stroke?

A

0-24 hrs

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20
Q

Goals of therapy for Acute Phase Treatment?

A
  • stabilization
  • reperfusion
  • supportive measures
  • prevent complications
  • prevent stroke recurrence
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21
Q

Describe the Acute Phase Treatment for an ischemic stroke.

A

ABCs

BPs

  • HTN common and transient in acute phase post stroke
  • Treat only if SBP > 220/120 mmHg, have evidence of aortic dissection, acute MI, pulmonary deem or hypertensive encephalopathy
  • aim for moderate reduction only (15-25%)
  • patients eligible to receive thrombolytic should target SBP < 185 and DBP < 110

Fluid, electrolytes, temperature

Glucose management

Neurological assessment

Early reperfusion

22
Q

Describe the options for reperfusion for an ischemic stroke

A

Thrombolysis with r-tPA (tissue plasminogen activator) is the gold standard

or

Endovascular Therapy (EVT)

23
Q

What is the inclusion criteria for Thrombolysis with r-tPA?

A
  • age 18 and up
  • ischemic stroke causing measurable neurologic deficit
  • r-tPA can be given within 4.5 hours of symptom onset
24
Q

What is the exclusion criteria for Thrombolysis with r-tPA?

A
  • only minor or rapidly improving stroke symptoms
  • any source of active hemorrhage or any condition that could increase risk of major hemorrhage after r-tPA
  • any hemorrhage on brain imaging
  • recent major surgery
  • SBP>185 or DBP>110 refractory to antihypertensives
25
Q

What is the dose for Thrombolysis with r-TPA?

A

Dose: 0.9mg/kg (max 90mg) over 1 hr, 10% IV bolus over 1 min

26
Q

What do you need to avoid with r-TPA?

A

anticoagulants or anti platelets for 24 hours

27
Q

What do you need to monitor for r-TPA?

A
  • BP
  • neurologic response
  • signs of bleeding/hemorrhage
28
Q

Describe EVT (endovascular therapy)

A

goes in femoral artery and goes all the way to cerebrovascular artery and retrieves the clot

29
Q

What is the criteria for endovascular therapy (EVT)

A
  • age > 18
  • functionally disabling stroke
  • infarct in a major cerebral artery
  • must be done within 6 hrs of stroke onset
30
Q

What is the point of taking anti platelets after an ischemic stroke?

A

-Reduces the risk of early recurrent stroke

31
Q

What dose and when should ASA be initiated after an ischemic stroke?

A

ASA 160 - 325 mg PO daily within 24-48 hours after stroke onset

32
Q

Describe combination anti platelets

A

Clopidogrel/ASA combo reduced risk of recurrent stroke without increased hemorrhagic stroke

Clop: LD = 75-300mg x 1 day
75 mg x 90 days
\+
ASA: LD = 300 mg x 1 day
75mg daily x 21 days

VS.

ASA: LD = 75-300 mg x 1 day
75 mg daily x 90 days

33
Q

When does combination anti platelet therapy need to be given?

A

within 12 hours of symptom onset

34
Q

What is the bottom line for Combining Antiplatelets?

A
  • ASA/clop combo not indicated in most cases due to concern of increased bleeding risk/hemorrhagic transformation
  • combo anti platelet therapy beyond 90 day not recommended for stroke prevention due to lack of benefit in long term secondary prevention and increased bleeding risk
35
Q

What type of patients are recommended to get LMWH or UFH?

A

For hospitalized patients with limited mobility for DVT prophylaxis

36
Q

When should LMWH or UFH be administered?

A

within 24-48 hours (avoid within 24 hr of thrombolytic)

37
Q

What is included in Acute Phase Monitoring for ischemic stroke?

A

1) Neurologic symptoms
- speech, extremity strength, facial symmetry
- worsening symptoms indicate recurrence or extension (i.e. presence of cerebral edema or increased intracranial pressure, or ICH)

2) Blood pressure
3) Electrolytes

4) Complications
- DVT/PE - calf/chest pain
- Infections (UTI or pneumonia symptoms, CBC, temp)

5) Adverse effects
- Signs of bleeding: Hgb, plt, INR

38
Q

Describe the surgical intervention options for secondary prevention of an ischemic stroke

A

1) CEA - Carotid Endarterectomy:
- Indicated for carotid artery stenosis of > 70% on the side of the neurologic deficit
- Only performed in experienced stroke centre

2) CAS - Carotid Artery Angioplasty and Stenting:
- Restricted to patients refractory to medical therapy and not surgical candidates
- Higher 30-day stroke/death rate vs. CEA

39
Q

What do we recommend for patients with noncardioembolic ischemic stroke or TIA?

A

the use of anti platelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events

40
Q

Describe ASA as secondary prevention of ischemic stroke

A
  • Most evidence and experience
  • Most common AE are dose related (upper GI discomfort, bleeding)
  • Least expensive
41
Q

Describe using ASA + Extended Release Dipyridamole (ERDP)

A
  • Dypyridamole no more efficacious than ASA alone
  • ASA 25 mg + ERDP 200 mg BID superior to ASA alone in secondary stroke prevention
  • ASA daily dose of 50mg insufficient for cardiac protection
  • Most common AE = (headache, dyspepsia, nausea, diarrhea)
  • Increased risk of bleeding with combination vs ASA alone
  • Cost/convenience not as favourable vs. ASA alone
42
Q

Describe using clopidogrel as secondary prevention for an ischemic stroke

A
  • No difference in stroke rate when compared to ASA
  • Similar risk of recurrent stroke when compared to ERDP-ASA - clopidogrel group showed less bleeding and headache
  • Most common AE (diarrhea, rash)
  • Less GI bleeding than ASA

-Cost

43
Q

Describe using ticagrelor as secondary prevention for an ischemic stroke

A

-Ticagrelor (180mg load + 90mg BID) not superior over ASA (300mg + 100mg daily)

44
Q

Should ASA and clopidogrel be used alone as secondary prevention for an ischemic stroke?

A

No benefit using them together. Just increases risk of bleeding.

45
Q

Describe using warfarin as secondary prevention for an ischemic stroke

A

Warfarin targeting an INR of 1.4 - 2.8 not superior to ASA 325mg for prevention of recurrent events. Increased bleeding risk with warfarin

**NOT recommended for noncardioembolic ischemic stroke

46
Q

What if a patient had recurrent stroke while taking ASA?

A

They don’t know what to do.
-No evidence to support one therapy vs another.

Were they taking ASA correctly?
-could increase dose from 81mg to 162 mg

Were they taking any other drugs that would interact with ASA?
ex. NSAIDs

47
Q

Secondary Prevention for Cardioembolic stroke:

What is recommended for patients with first and recurrent stroke in non-valvular atrial fibrillation?

A
  • Warfarin with target INR = 2.5
  • Apixaban
  • Dabigatran: Exceptions Clcr < 15 mL/min
  • Rivaroxaban is reasonable
  • For patients unable to take oral anticoagulants, ASA alone is recommended.
48
Q

Describe DOACs (direct oral anticoagulants) as secondary prevention for cadioembolic stroke

A
  • Relatively new on the market
  • No measure of anticoagulation state
  • No reversible agent in cases of severe, life-threatening bleed
  • Not approved for patients with valvular AF
49
Q

What else is key in secondary prevention?

A
  • Blood Pressure Lowering
  • Statin Therapy
  • Diabetes Management
  • Lifestyle Changes
  • Depression Screening
50
Q

Why is Blood Pressure Lowering key in secondary prevention?

A
  • Crucial for both ischemic and hemorrhagic stroke prevention (for primary prevention as well)
  • Acute stroke period: Maintain SBP 141-150 - risk of decreased cerebral blood flow and worsened symptoms if aggressive BP lowering
  • Antihypertensive can be restarted 24 hr after stroke if needed
  • Long term BP control: target BP < 140/90

**CHEP recommends ACEi/diuretic combination; however, selection of agent not as important as BP control

51
Q

Why is Statin therapy key for secondary prevention?

A

Statin recommended as secondary prevention for most patients who have had an ischemic stroke or TIA; target LDL < 2.0 mmol/L, or a 50% reduction in LDL from baseline

52
Q

What lifestyle changes are recommended as secondary prevention?

A
  • smoking cessation
  • avoid alcohol consumption
  • increase physical activity
  • weight loss
  • diet less in saturated fat

Clinical 2 (Sam) (18 decks)

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