Acute Ischemic Stroke Flashcards

(37 cards)

1
Q

Common stroke sx

A

sudden onset unilateral focal neuro deficit
* dysphasia,dysarthria
* hemianopia
* weakness
* ataxia
* sensory loss
* neglect

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2
Q

Stroke severity

A

Assess using NIHSS
1-4 = minor stroke
21-42 = severe stroke

Small stroke: no visible difference MRI
Large stroke: large vessel occlusion

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3
Q

Acute stroke diagnosis

A

Confirm NIHSS (+) stroke
Confirm sx dt ischemia +r/o other neuro deficit
Consider stroke mimics

Imaging!!!
1. non contrast CT head r/o hemorrhage
2. MRI sensitive for detecting early ischemic changes

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4
Q

Ischemic vs hemorrhagic stroke on imaging

A

Ischemic: not seen until 12-24 hr post event
Hemorrhagic: shows up 1-2 hrs post event on CT

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5
Q

Ischemic Stroke Mimics - neurological

A
  • seizure/post ictal
  • complicated migraine
  • otherintracrainal process (infx, abcess, hemorrhage, MS)
  • HTN encephalopathy
  • Vertigo
  • Crania/peripheral neuropathies
  • Bells palsy
  • transient global amnesia
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6
Q

Ischemic Stroke Mimics - Metabolic

A

Hypo/hyperglycemia
Low sodium
hepatic encephalopathy
Drug overdose

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7
Q

Ischemic Stroke Mimics - Psychiatric

A

Conversion disorder
malingering

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8
Q

Post stroke regimen

post TPA

A
  1. Neuro/BP monitor x 24 hrs (neuro decline usually occurs first 24-48hr post)
  2. Dysphagia/aspiriation risk
  3. HIGH INTENSITY STATIN
  4. AntiPLT:
    * Everyone: spirin 81 mg
    * Low NIH or stent: 21 day DAPT
  5. DVT prophy once >24 hr post TPA
  6. Anticoag: if cardioembolic stroke or hx afib
    * large = 7-14 days
    * small = 3-5 days
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9
Q

Stroke Prevalence

ischemic

A

4th leading cause death
cerebral ischemia = 87% strokes/yr that occur in US

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10
Q

Post-stroke deficits

complications

A

50% hemiparesis
46% cognitive decline
35% depression
30% inability to ambulate w/o assistance
23% PTSD

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11
Q

Risk factors of Ischemic Stroke

A

Hypertension
Cigarette smoking
Diabetes
Dyslipidema
Arrythmia conditions
Post menopausal hormone therapy (estrogens)
Oral contraceptives
Physical inactivity
Obesity
Harder to modify:
- asymptomatic carotid stenosis
- sickle cell disease

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12
Q

CH A2 D S2-VASc

A

Congestive HF
HTN
Age
Diabetes
Stroke/TIA hx 2pt
Vascular disease
Female

age 75+ = 2pts

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13
Q

Ischemic stroke patho

A

ischemia dt excess extracellular amino acids, free radicals, inflammation

Atherosclerotic plaque rupture
Cardiogenic afib - embolism = 20% strokes

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14
Q

Acute stroke management

within 4.5 hrs sx onset

A

Fibrinolysis of no C/I
If large vessel stroke = thrombectomy

if small vessel occlusion = only heparin infusion
if >4.5 hrs, no TPA

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15
Q

IV fibrinolytic contraindications

A

<18
within 3 mon:
* ischemic stroke
* intracranial/spinal surgery
GI malignancy/BIG within 21 days
LMWH within 24 hrs
Infective endocarditis
intra-axial intracranial neoplasm

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17
Q

IV fibrinolytics OK use

once you correct the problems

A

Seizure at onset
hypo/hyperglycemia
arterial puncture at non-compressible site in last 7 days
recent major trauma if not involving head in last 14 days
recent major surgery within 14 days

18
Q

IV fibrinolytic choices

A
  1. alteplase
  2. tenecteplase
19
Q

alteplase dose

A

0.9 mg/kg
Max dose 90mg
Bolus: 10% IV bolus over 1 min
Infusion: 90% total dose over 60 min

20
Q

alteplase half life

A

5 minutes
80% cleared from plasma within 10 minutes
super short acting

21
Q

tenecteplase dose

A

0.25 mg/kg
Max dose 25mg
IV push dt longer half life

22
Q

tenecteplase half life

A

20-24 minutes
terminal: 99-120 min

23
Q

TPA specficity

A

tenecteplase 15x fold increase in fibrin specificity vs alteplase

24
Q

BP for TPA bolus

25
BPA for TPA infusion
<180/105 | more fluid, lower bp goal than bolus
26
BP if not qualify TPA
permissive HTN no treat unless >220/110 to maintain brain perfusion
27
Hypotension vs stroke
low bp can worsen ischemia
27
HTN vs Stroke
>220/120 detrimental = risk of hemorrhagic conversion
28
BP control first line
IV labetalol bolus IV nicardipine if HR < 55
28
BP control 2nd line
hydralazine enalaprilat clevidipine
29
Alteplase usage data
increased sx ICH (hemorrage risk)
30
Alteplase vs timing | alteplase use ≥4.5 hrs
Wakeup/EXTEND trials extended time frame TPA = improved functional outcomes as long as use MRI/CT guided scan for pt TX inclusion
31
Tenecteplase usage data
EXTEND-IA trial: ≤4.5 hrs w/ large vessel occlusion as good as alteplase if not better reperfusion/functional outcomes when used with thrombectomy
32
TPA complications
Symptomatic ICH 1. DC TPA 2. Cryoprecipitate 10 units over 10-30 min (supplements fibrinogen by 30-60 mg/dL) 3. Anti-TPA: tranexamic acid 100mg IV or e-aminocaproic acid 4-5g IV Angioedema 5% patient, ACEI risk factor 1. maintain airway - intubate before too late 2. Hold ACEi 3. IV steroid: MnPn 80-100mg IV 4. Benadryl 50mg IV 5. Ranitidine 50mg IV or famotidine 20mg IV 6. EPI 0.3mL 7. watch for swelling to come down | anti-TPA: displace plasminogen from fibrin (inhibit fibrinolysis)
33
thrombectomy | Endovascular intervention
for large vessel occlusions +/- use of IA thrombolytics
34
secondary stroke prevention
lifestyle/nutrition smoking cessation limit alcohol consumption counsel SUD HTN Dyslipidemia Diabetes
35
MR CLEAN trial | thrombectomy
IA alteplase +/- thrombectomy = significant improvement in functional outcome no difference in mortality or ICH