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Stroke Flashcards

1
Q

What is the gold standard for diagnosing stroke?

A

Non-contrast head ct

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2
Q

Stroke can lead to what two diseases?

A

Depression and Dementia

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3
Q

What is the cause of hemorrhagic stroke?

A

Bleeding

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4
Q

What is the cause of ischemic stroke?

A

Clotting

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5
Q

Patho of hemorrhagic stroke

A

Hematoma is formed in the parenchyma without blood extension into the ventricles. Subsequent bleeding around the clot causes swelling

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6
Q

In ICHS- swelling around the hematoma causes

A

Increase risk of mortality

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7
Q

What can the non contrast head Ct confirm?

A

Size, edema, raised intracranial pressures and what kind of stroke it is

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8
Q

Why don’t we use MRI

A

Takes more time and less readily available

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9
Q

What are some parameters to diagnose hemorrhagic stroke?

A

Unresponsiveness
Elevated BP
Neck pain
Vomiting
Seizures
*these do not differentiate between strokes but can give clues if it is hemorrhagic

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10
Q

What is the first thing that should be done to treat a patient with stroke?

A

Stabilize- ABCs

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11
Q

What is ABCs?

A

Airway
Breathing
Circulations

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12
Q

What lab test should be ordered with the head ct either during or before?

A

Glucose finger stick

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13
Q

What is one main mimic of stroke to look for?

A

Hyperglycemia - so fix and will go away

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14
Q

If patient is on an anticoagulant we need to reverse it, why?

A

Coagulation is a factor deficiency and needs to be corrected

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15
Q

Reversal for warfarin(vit k antagonist)

A

Give vit k with PCC
Or FFP

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16
Q

Why is PCC chosen over FFP?

A

Faster reversal and religious reasons may not want FFP

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17
Q

Davigatran reversal:

A

Idaruciumab

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18
Q

Xa inhibitors:

A

Andexant alfa or PCC if unavailable

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19
Q

Heparin:

A

Protamine sulfate

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20
Q

Should we do platelet infusions?

A

No, platelet transfusion increases the risk of death or dependence if patient is on anti platelet therapy.

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21
Q

What is the one exception that we can give platelets?

A

If platelet count < 100,000

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22
Q

When should we manage BP?

A

If greater than 185/110
If less than—-don’t treat

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23
Q

What agents do we use for BP control?

A

Nicardipine
Labetolol
Clevidipine

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24
Q

What is the difference between nicardipine and labetolol?

A

Nicardipine infusion is nice smooth drop of Bp as to labetolol is more choppy (iv push)

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25
If bleed is in the cerebellum what should we do?
Surgical emergency
26
If ich ruptures into ventricles and intravascular hematoma, it can form a thrombis and obstruct outflow causing: What should we do?
Hydrocephalus External ventricular drain
27
What if there are seizures?
We treat them but never use as prophylaxis
28
What other treatments should we do?
Pain and fever with acetaminophen Maintain euglycemia DVT prophylaxis- give pneumatic compression stockings
29
For DVT when can we give an anticoagulants?
Heparin or LMWH 1-4 days after
30
If intracranial HTN happens give?
Osmotic therapies - hypertonic saline or mannitol
31
What is an hemorrhagic transformation?
Bleeding in the area of the ischemic brain after stroke Caused by peripheral blood in bbb disruption usually after tpa given Increased m&m Essentially ischemic to hemorrhagic
32
What are the risk factors for hemorrhagic transformation?
Reperfusion therapy, stroke severity, HTN, age, hyperglycemia, inflammation and immune system
33
What is the treatment for hemorrhagic transformation?
Reversal agents for tpa 1. Cryoprecipitate 2. FFP, PCC, vit k 3. Antifibrinolytics - amino caprock and tranexamic acid
34
What is the goal of cryoprecipitate?
Increase fibrinogen by 60mg/dl Goal: >/= 150 mg/dL
35
When should we give FFP, PCC, vit k?
For patients who were on warfarin and inr < 1.7 prior to tpa
36
When should we give the antifibrinolytics?
In patients who don’t want blood products
37
The majority of strokes is ?
Ischemic
38
What is a transient ischemic attack?
Stroke that is not permanent Caused by cerebral edema Temporary blockage of artery Patients are at a higher risk for subsequent strokes
39
What is the ABCD2 score?
To asses the risk of future strokes
40
How do you score patients in the ABCD2?
0-3: low risk 4-5: moderate risk 6-7: high risk Patients with high risk are admitted to hospital for imaging
41
Tia is a ——- for stroke
Warning sign
42
What are the modifiable risk factors for stroke?
Smoking , diabetes, HTN, hyperlipidemia
43
Ischemic strokes 2 types?
Thrombotic and embolic
44
Thrombotic is caused by
Artherosclerosis
45
In thrombotic: large vessels and Small vessel is?
Large vessel: extracranial ( internal carotids) and intracranial (middle/ anterior cerebral artery) Small vessel: lacunar
46
What is an embolic stroke?
An occlusion or embolus starts inside the brain and moves to the vascular of the brain
47
What is an ischemic stroke?
Decrease or complete blockage of blood flow to a vessel in the brain Irreversible and neuronal death of neuron function
48
What is the cause of ischemic stroke?
Decreased systemic perfusion, severe stenosis, or occlusion
49
What are the 2 layers of ischemic stroke?
Ischemic/ inner core and penumbra
50
Most of the medications work on what layer of the ischemic stroke?
The penumbra since does not die right away and can get blood form nearby arteries—-supplies nutrients and oxygen
51
What is the NIH stroke scale?
Determines stroke severity
52
What is the scoring of the NIH?
1-4: mild 5-14: moderate 15-25: moderate to severe 25-42: severe Should do scale within 25 minutes on arrival
53
When should you consider the stroke as ischemic?
If no bleeding
54
What if the non-contrast ct is normal?
It may appear normal for an early stroke so: Consider stroke mimics
55
What are the common stroke mimics ?
1 migraine syndromes 2. Seizure disorders 3. Hyper/hypoglycemia Neuro deficits won’t be permanent
56
Consider if patient is an candidate for fibrinolytic?
Yes- give tpa within 60 minutes No- give aspirin
57
Once you rule out bleeding and mimic concerns:
Consider reperfusion therapy
58
If you can’t rule out mimics what did you do?
If you have high suspicion for ischemic stroke and went through the list of mimics- then give tpa
59
What is reperfusion therapy?
1 thrombolytics/ fibrinolytics 2 interventional therapy- endovascular
60
Which tpa is fda approved?
Alteplase
61
When to give endovascular therapy?
Within 6 hours and need to have large vessel occlusion 1 mechanical thrombectomy 2 aspiration thrombectomy
62
What are the tpa time frames?
0-3 hrs: yes 3-4.5 hrs: yes but with limitations 4.5-6 hrs: wake-up
63
Tpa is generally indicated for —- hrs?
4.5
64
Tpa moa:
Activates plasminogen converts to plasmin then chews fibrin and breaks it down to fibrin degradation products.
65
What is the modified rankin scale?
Determines a persons level of disability
66
What is the modified rankin scale scores?
0: none 1: symptoms 2: slight disability 3: moderate disabilities - need help but can walk with out help 4: mod/severe disabilities - unable to walk without help 5: severely 6: dead almost
67
Neuro deficits and mrs scores have no impact on mortality:
Tpa improved and reduced the risk of life disability after a stroke
68
How long should we monitor after given tpa?
24 hrs for signs of hemorrhagic transformation Risk vs benefit discussion- can sign consent but not required
69
What are the contraindications for tpa?
Stroke is mild and non disabling Head issues/ trauma Cerebral infarction Malignancies or bleeding within 21 days Endocarditis Aortic arch dissection Platelet < 100,000 Inr>1.7 Aptt> 40 seconds Pt> 15 seconds BP> 185/110 If had lmwh in 24 hrs or Xa I in 48 hrs unless labs are normal or patient did not get a dose
70
What does the aptt tell us?
Shows recent use of heparin or dvt prophylaxis of heparin.
71
When is it beneficial if you give tpa in the 3-4.5 hr timeframe?
>80 years old History of stroke and DM Warfarin use with inr<1.7
72
What is the tpa dosing?
0.9 mg /kg 1 bolus: 10% of total iv push in 1 min 2 infusion of 90% in 60 min
73
What are the action times?
Physician: 10 min Stroke team: 15 min Ct scan: 25 min Interpret ct: 45 min Needle time: 60 min
74
Endovascular therapy criteria?
With in 6 hrs of onset Mrs score of 0-1 Large vessel occlusion Age 18 years old NIHSS: >\= 6 ASPECTS: >/= 6 *no perfusion imaging required
75
What does ASPECTS score do?
Look for signs of ischemia
76
How do you score ASPECTS?
Low score= increased signs for ischemia and greater likelihood of disability after stroke 10=normal
77
Should patients receive alteplase if eligible even if thrombectomy is being considered?
Yes
78
How do you look for large vessel occlusions?
Ct angiogram or magnetic resonance angiogram
79
What are the limitations for endovascular therapy?
Few patients meet criteria and limited centers and qualified personnel
80
Post stroke what is the main reason for m&m?
Aspiration
81
When should you give aspirin in stroke patients?
24-48 hours post, could be given earlier if using a stent If can’t give aspirin- use clopidogrel
82
How long should DAPT be initiated?
21 days because with 90 there was increased risk for hemorrhaging
83
When do you give DAPT?
Give to patients with minor non cardio embolic stroke with out tpa administration (NHSS<4) within 24 hrs of symptom onset
84
What is the dosing for DAPT?
Clopidogrel 300-600mg loading dose then 75 mg qd, aspirin 81mg qd
85
Ticagrelor not recommended why?
Increased risk of bleeding but could be used if clopidogrel is not an option 180mg loading then 90mg BID
86
What did you do if BP is >220/110 mmHG?
Give treatment. Lower by 15% in 24 hr
87
What if BP is < 220/110
Do not start treatment within 48-72 hrs = no benefits
88
DVT prophylaxis?
Use IPC and ASA + hydration Heparin not recommended
89
How do you prevent 2’ stroke?
Treat their HTN, DM, dyslipidemia, Afib, carotid artery stenosis
90
2’ stroke prevention guidelines:
Anti hypertensive- if >\= 140/90 or already on meds Antithrombotic therapy- anticoagulants for cardio embolic strokes Antiplatelets for atherosclerosis strokes Statin therapy- high dose Lifestyle- reduce alcohol
91
For afib what anticoagulant?
DOAC > warfarin

Isbp (4 decks)

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