Flashcards in Cerebrovascular Dz Deck (55):
How is an ischemic CVA caused?
Reduction of blood supply to different areas of the brain due to obstruction of blood vessel
Obstruction can be d/t:
What are the 2 types of ischemic CVA? Definition?
Thrombotic--local vessel obstruction
Embolic--clot travels from somewhere else to the brain & obstruct a cerebro-vessel
Definition of Transient Ischemic Attack (TIA)?
-brief episode of neurological dysfunction caused by focal brain or retinal ischemia w/ clinical sx lasting <1hr
-w/o residual neurological dysfunction
Definition Ischemic CVA
IRREVERSIBLE damage occurs
w/ residual neurological defect
Risk Factors for Ischemic CVA
-Hx non-cardioembolic stroke
Which of the following is a risk factor specific for EMBOLIC stroke?
b. Carotid Stenosis
Risk factor for cardio-EMBOLIC stroke only
Presentation of Ischemic CVA
-may vary depending on parts of brain involved
-ataxia (+/- vertigo)
-one sided sensory sx
Which of the following is NOT a sx of ischemic CVA?
b. loss of vision
B. loss of vision
pt may have gaze deviation
What therapeutic class drugs are appropriate 1st choice therapy for a Non-Cardioembolic stroke (not from a-fib)?
B. Antiplatelet therapy
Aggrenox (ASA +dipyridamole) BID
Clopidogrel (Plavix) 75mg/day
When would you give ticagrelor in a pt with a non-cardioembolic stroke?
If they have an aspirin allergy
Not inferior to aspirin, can be used as alternative option--can cause more bleeding
Which antiplatelet drug would you to start a pt on with noncardioembolic stroke that isn't being treated with a thrombolytic?
What therapeutic class of drugs are appropriate therapy for cardio-embolic stroke (from a-fib)?
Warfarin (INR 2-3)
Dabigatran (150mg BID)
Rivaroxaban (20mg daily)
Apixaban (5mg BID)
Edoxaban (60mg daily)
What pathway of the clotting cascade do anticoagulant affect?
What is CHA2DS2-VASC used for?
Determines risk of a cardioembolic stroke for pt w/ a-fib ONLY
What does CHA2DS2-VASC stand for?
Age >75yo / 65-74yo
Vascular Dz (MI, PAD)
Which 2 risk factors from CHA2DS2-VASC counts for 2points
If a pt has no risk factors for thromboemoblism, what drug therapy should they be on?
If a pt has 1 risk factor for thromboembolism which drugs could they be on?
If a pt has 2 or more risk factors for thromboembolism, which drugs could they be on?
Whether the pt had a thrombotic or embolic stroke, what other class of drugs should the pt be on?
What statin should the pt be on and what dose?
Atorvastatin 80mg once a day
REGARDLESS of cholesterol profile
GI bleed, stomach upset
ASA 25mg + Dipyridamole 200mg (aggrenox)
Dose to INR 2-3 indefinitely
INR, consistent vit K intake, DDI
Direct Anti-Xa inhibitors Monitor
What are the direct oral anticoagulants (DOA)?
Which of the DOA are dosed BID?
Which DOA are MORE EFFECTIVE than warfarin?
Which DOA is a direct thrombin inhibitor?
Which of the following drugs are eligible for a pt w/ cardioembolic stroke & CKD?
What is the initial approach for a pt coming in with a CVA
-eval for eligibility for thrombolytic therapy
-plan on initiating/re-initiating antiplatelet, antithrombotic therapy
-conservative HTN mgmt
-Mgmt underlying etiologies for stroke
-other supportive care
What does thrombolytic therapy do?
What are pt at high risk for if on thrombolytic therapy?
What is time frame allows for admin of thrombolytic therapy after a stroke?
d. any time
B. 3.0-4.5 hrs after stroke
given over 1hr
Once a thrombolytic has been administered, what is the following steps of their mgmt?
-IVF NS at 75-100mL/hr
-No blood thinners for 24hrs (heparin, warfarin, ASA, clopidogrel or dipyridamole)
-get brain CT/MRI at 24hrs
If pt wasn't eligible for thrombolytic, how should they be managed?
-IVF NS at 75-100mL/hr
-Aspirin 325mg w/i 1st 24hrs of hospital admission
-Anticoagulants (heparin/warfarin) in cardioembolic stroke AFTER 24hrs & pt is STABLE
-Repeat brain CT/MRI 24-48hrs after stroke or prn
If pt is given tpA at 2pm, can they take their aspirin at 10am the next day?
NO. they can't restart any blood thinner within 24hrs after admin of tpA
Pt started experiencing dysarthria, hemiparesis, and face asymmetry, at 4pm and arrived at the ER at 10pm. No a-fib, They're on aspirin 81mg, labetolol 10mg and simvastatin 15mg. How would manage this pt?
Pt isn't eligible for tpA bc they arrived over >4.5hrs after the stroke occurred.
-Give them higher dose aspirin (325mg) within 24hrs of admission
-give them intensive statin therapy (atorvastatin 80mg)
Can pt be on anticoagulants for DVT/PE prophylaxis within 24hr of stroke?
-bleeding risk is small bc dose is tiny
-used to prevent DVT as complication of stroke bc pt will be bed bound; NOT used to tx the stroke
Low dose heparin (5000units sc BID or TID)
LMWH (Enoxaparin 30 or 40mg QD)
Fonadaparinux (2.5mg SC QD)
Complications Post Acute Ischemic Stroke
What BP lvl is the cut off for thrombolytic therapy?
What can be given to pt w/ BP >220/140
Labetalol or Nicardipine
Can add Nitroprusside if uncontrolled
What % reduction of BP are you aiming for?
Is BP 210/140 eligible for thrombolytic therapy?
Yes! just need to lower it to be <185/110
w/ antihypertensive therapy (BB or CCB)
How would you manage a pt w/ BP 185/110
-Check BP q15min for 2hr, then q30min for 6hrs, then q1hr for 16hrs
-Labetalol (may repeat or give nitropaste) or
-if uncontrolled, add Nitroprusside
-Aim for 10-15% reduction of BP
IV Heparin, monitor?
aPTT 1.5-2.5x baseline
sign of tachyphylaxis (when used for >2-3 days continuously)