Exam 4 lecture 6 Flashcards
Does ischemic stroke have worse prognosis or hemorrhagic stroke?
Hemorrhagic
Distinguishing symptom of hemorrhagic stroke
Severe headache
acute hemorrhagic stroke management
-Supportive care
-glycemic control
-Reversing causative medications
-surgery
-antihypertensives
-prevention of cerebral vasospasm
-anticonvulsant
reversing causative medications for
warfarin, Heparin, DOACs (dabigatran, other DOACs), ANtiplatelets
Warfarin- vitamin K
Heparin products- protamine
DOAC
Dabigatran- idarucizumab
Other DOACs- recombinant coagulation factor Xa
ANtiplatelets: No antidote
When to use antihypertensives in acute hemorrhagic stroke? WHat are the goal BPs?
SBP>180
Goal BP first 24 hrs < 180/110
Goal BP in hospital after 24 hours is < 160/90
After 48 hrs, transition to outpatient goal BP
What are patients at risk for after a subarachnoid hemorrhagic stroke
Vasospasms
highest risk 4-21 days after subarachnoid hemorrhagic stroke
Worsens complications after stroke
What drug has been shown to minimize complications from cerebral vasospasm?
Nimodipine
Is there a risk of seizure after hemorrhagic stroke?
Yes, there is a risk of hemorrhagic stroke
How should we avoid seizures caused by hemorrhagic stroke
Prophylactic anticonvulsants are NOT recommended due to lack of benefit.
Anticonvulsants only used if patient has a documented seizure history
What to use for Ischemic stroke patients to prevent secondary strokes
Antiplatelet vs anticoagulants
atherosclerotic- antiplatelet
cardioembolic- anticoagulants
goal of antiplatelet drugs? Duration
(Aspirin)
goal- prevent future strokes through inhibition of platelet activation/aggregation
duration- indefinite until bleeding risk/complications
What is the 1st line tx for secondary stroke prevention in atherosclerotic stroke? dose? Monitoring?
first 2-4 weeks Aspirin (162-325)
after 2-4 weeks of high dose aspirin do < or equal to 162 mg/day indefinitely
bleeding, nausea
Can also use dipyridamole/Aspirin
MOA of dipyridamole/Aspirin? Place in therapy? How is it used?
MOA- inhibits adenosine phosphodiesterase , preventing platelet aggregation
Also first line therapy for secondary stroke prevention in atherosclerotic ischemic stroke.
Not used acutely . Start after using 2-4 weeks high dose aspirin after stroke
side effects of dipyridamole/aspirin
Headache
GI bleed
WHat is a second line option for secondary stroke prevention in non embolic ischemic stroke for aspirin intolerant
Clopidogrel
mostly used in combination with apsirin
What is the place in therapy for clopidogrel + aspirind
Secondary stroke prevention for atherosclerotic ischemic stroke, first line for minor strokes. Second line for moderate-severe strokes
WHat are antiplatelets we do not use for secondary prevention
Ticagrelor + aspirin and prasgurel
FIrst line options for secoondary prevention of strokes
Aspirin
Dipyridamole/aspirin
Clopidogrel + aspirin
2nd line options for secondary prevention of strokes
Clopidogrel
What type of stroke patients are anticoags reserved for
Cardioembolic stroke patients caused by A fib (EXAM), valvular heart disease or severe HF
When to initiate anticoag
2-14 days after stroke
Immediately after stroke use aspirin instead of anticoag as lower bleeding risk
once anticoag starts, dx aspirin
What are anticoags to be used for cardioembolic stroke
DOACs
Apixaban
dabigatran
edoxaban
rivaroxaban
Warfarin
What anticoags to use if patient has mitral valve/LV thrombus
Warfarin/rivaroxaban
What are antiplatelets and anticoags used for?
only used in ischemic strokes (not hemorrhagic) to prevent occlusion of brain vasculature to minimize risk of future strokes
