Stroke Flashcards
(51 cards)
1
Q
What is the epidemiology of Stroke?
A
- 800,000 Strokes yearly
- 5th cause of death
2
Q
What is the defintion of a Stroke?
A
- An acute focal injury due to lack of blood/oxygen to the CNS causing Neurological deficits
3
Q
What are the two types of stoke?
A
- Ischemic
- Hemorrhagic
4
Q
What is the definition of Ischemic Stroke?
A
- An infarction of brain tissue resulting fom compromised blood flow
- Atherosclerotic: Increased plaque = Decreased Blood Flow
- Cardioembolic: Embolism from Afib
5
Q
What is the definition of Hemorrhagic Stroke?
A
- Bleeding in the brain due to rupture of a cerebral artery - Aneurysm
- Intracranial Hemorrhage
6
Q
What are some of the risk factors for Stroke?
A
-
Non-Modifiable: Age, Family History, Females > Male, Race, Birth Weight, Sickle Cell
Modifiable: CV Diseases, Diabetes, Hyperlipidemia, HTN, Alcohol, Obesity, Smoking
7
Q
What is are some of the clinical presentations for Stroke?
A
- Difficulty Speaking
- Facial Droop
- Weakness
- Ataxia
- Vision Changes
- Headache [more common in Hemorrhagic]
8
Q
What does FAST mean within Clinical Presentation in Stroke?
A
- F: Facial Droop
- A: Arm Weakness
- S: Speech Difficulty
- T: Time to call 911
9
Q
What are some of the assessments used to help determine a stroke?
A
- Imaging [Head CT or MRI}
- Vitals [BP or Oxygen Sat}
- Lab [BG, BMP, CBC, Hematologic Markers]
- Test [ECG or Echo]
10
Q
What is imporant to know about Imaging in Assessment with Stroke?
A
- Head CT or MRI
- A quick way to see what is happening within the brain
11
Q
What is important to know about Tests [ECG] in Assessment within Stroke?
A
- AFib = Cardioembolic
- Noraml = Atherosclerotic
12
Q
What are some of the Goals of Treatment for Acute Stroke?
A
- Limit Neurological Injury
- Decrease Mortality
- Prevent Future strokes [After 1st stroke, increased risk of others]
13
Q
What is the Acute Managment Overview for Stroke?
A
- Supportive Care
- Glycemic Control
- Antihypertensives
- Thrombolytics
- Antiplatelets
- Anticoagulation
14
Q
What is important to know for Glycemic Control in Acute Managment of Stroke?
A
- Hypoglycemia: causes neuro changes that “mimics” stroke –> GIVE CARBS
- Hyperglycemia: BG > 180mg/mL has Increased Morbidity & mortality –> GIVE INSULIN until BG < 180mg/mL
15
Q
What should you do if a patient is Hyperglycemic and in Acidosis within Stroke?
A
- Insulin Drip
16
Q
What is important to know about arguing FOR or AGAINST Acute Blood Pressure Management in Stroke?
A
- FOR: Minimize neuro deficits, Decreased cerebral edema & hemorrhage, Prevention
- AGAINST: decreased BP to quickly can limit the brain perfusion = worse ischemia & neuro function
17
Q
What are some fo the blood pressure goals for Acute Management of Blood Pressure in Stroke
A
- Check BP every hour
- GOAL within 48h: NO tPA = <220/110 & WITH tPA = <180/105
- After 48h: <140/90 or <130/80
18
Q
What are some of the Acute Hypertension Treatment options for Acute Management of Blood Pressure in Stroke?
A
- Labetalol, Nicardipine, Sodium Nitroprusside
19
Q
What are the Thrombolytics that are used in Acute Ischemic Stroke Management?
A
- Alteplase, Tenecteplase
20
Q
Based on the mechanism of action for Thrombolytics, what type of Stroke would you use a Thrombolytic in?
A
- Activates plasminogen which helps break apart the clot
- Ischemic [both atherosclerotic and cardioembolic]
- NOT in Hemorrhagic [increases bleed risk]
21
Q
What is important about using Thrombolytics in Ischemic Stroke?
Types? What does it help?
A
- BOTH TYPES - Athero and Cardio
- NO impact on mortailty but could improve neuro function
- ONLY IN PATIENTS THAT MEET CRITERIA
22
Q
What is the tPA Eligibility criteria for Stroke?
A
- Inclusion: Ishchemic Stroke ONLY & symptom onset <4.5 hours
- Exclusion: increased bleeding, BP > 185/110 & BG<50mg/dL
23
Q
What are the two tPA agents that are used ?
A
- Alteplase 0.9 mg/kg IV [MAX 90 mg]
- Tenecteplase 0.25 mg/kg IV [MAX 25mg]
24
Q
What are some side effects from tPA agents in Stroke?
A
- Bleeding [increases hemorrhage risk] - KEEP BP < 180/105 & avoid ALL antiplatelet and Anticoag for 24h
- Cerebral Edema
25
What are the Antiplatelet options for Acute Ishemic Stroke Management?
- **Aspirin**
- Aspirin + Clopidogrel
- Ticagrelor
- Aspirin + Ticagrelor
26
What is important to know about Aspirin in Acute Ischemic Stroke Management?
| MOA? When?
- MOA: **Irreversible** inhibitor of COX enzyme; reducing fromation of TXA2 = decreased platelet aggregation
- **FIRST LINE**
- **325 mg daily** for 2-4 weeks
27
Who gets aspirin for a stroke?
- **ALL** ischemic stroke [both **Embolic and Atherosclerotic**]
- Contraindications: **Bleeding**
- >24h **if** tPA given [**NO tPA** then immediately]
28
What important to know about Aspirin + Clopidogrel in Acute Management of Stroke?
- MOA: Clopidogrel = P2Y12 inhibitor that decreases platelet aggregation by blocking ADP
- **ONLY** for minor strokes [NIHSS < 4]
- **Second Line**
29
What is important to know about Ticagrelor in Actue Management of Stroke?
- P2Y12 inhibitor that decreases platelet aggregation by blocking ADP
- **ONLY** for minor strokes [NIHSS < 5]
- **Second Line**
- Used when **True** aspirin allergy
30
When should you use therapeutic Anticoag be used within Acute Management of Stroke?
- **LACKs** research - no improvement of neuro & **Increased Bleeding**
- **USE ASPIRIN**
31
What do you do if the patient comes in on an anticoagulant?
- **D/C** anticoag --> **START** aspirin
- **NO** alteplase if on Anticoag
32
If the Patient is Cardioembolic what should you do with anticoagulant?
- **Start > 2-14 days after stroke**
33
What is the Acute Management overview of Hemorrhagic Stroke/
- Reversal Agents
- Surgery
- Prevention of Cerebral Vasospasm
- Anticonvulsants
34
What are some of the Reversing Causative Medications that could be used in Acute Management of Hemorrhagic Stroke?
- **Vitamin K** = Warfarin
- **Protamie** = Heparin
- **Idarucizumab** = Dabigatran [DOAC]
- **Andexxa** = Other DOAC
- **NOTHING** = Antiplatelets
35
What are some fo the surgical options for Acute Management for Hemorrhagic Stroke?
- Craiotomy, Endoscopic Coiling, Endoscopic Evacuation
36
When should Antihypertensives be used in Acute Hemorrhagic Stroke?
- **Prevent** rebleeding by **controlling BP**
- GOAL: **first 24h** = <180/110
- GOAL: **after 24h** = <160/90
- GOAL: **after 48h** = < 130/80 or <140/90
37
What is the way that we are able to prevent Vasospasm in Acute Management of Hemorrhagic Stroke/
- Vasospasms after **Subarachnoid** Hemorrhagic Stroke [4-21d after]
- **Nimodipine** decreases vasospasms [60mg q4h x 21d]
38
When should Anticonvulsants be used in the Acute Management of Hemorrhagic Stroke?
- **Increased** risk of seizure after stroke
- Prophylactic **NOT** recommended
- Use **ONLY** is history of seizure
39
What is the goal of Antiplatelets in Secondary Stroke Prevention?
- **Prevent** future strokes by **inhibition of platelets**
- **INDEFINITE TREATMENT**
40
What is the goal of Aspirin in Secondary Stroke Prevention?
- **FIRST LINE**
- Start with **325mg** then switch to **81mg**
- SE: **Bleeding, Nausea**
41
What is the goal of Dipyridamole/Aspirin [**Aggrenox**] in Secondary Stroke Prevention?
- MOA: Both inhibit the aggregation fo platelets
- **FIRST LINE**
- SE: **Headache & GI Bleeds**
42
What is the goal of Clopidogrel in Secondary Stroke Prevention?
- **SECOND LINE** - mainly used in **Atherosclerois**
- SE: **Bleeding**
43
What is the goal of Clopidogrel + Aspirin in Secondary Stroke Prevention?
- For **Minor Stroke** [NIHSS < 3] = 1st line & **Mod-Severe** = 2nd Line
- SE: Bleeding [increased in combo]
44
What are some fo the Other Antiplatelets in Secondary Stroke Prevention?
- Ticagrelor + Aspirin
- Prasugrel
- **NOT RECOMMENDED in guideline as treatment**
45
When should anticoagulants be used in Secondary Stroke Prevention?
- In **Cardioembolic** stroke caused by **AFIB** --> start > 2-14d after stroke
46
What are some of the anticoagulants that are used in Secondary Stroke Prevention?
- DOAC [Apixaban, Dabigatran, Edoxaban, Rivaroxaban]
- Warfarin
- **MECH VALVE = Warfarin/Rivaroxaban**
47
What is the Hypertension Management goal for Secondary Stroke Prevention?
- GOAL BP **<130/80** for **ALL** stroke types
48
What is the Hypertensive medications for Secondary Stroke Prevention?
- Black: **CCB, Thiazide**
- CKD: **ACEi, ARBs**
- CAD: **BB+ACEi [or ARBs]**
- DM: **ACEi, ARBs**
- HFrEF: **ARNI, ACEi, or ARBs + BB + Aldosterone Antagonist [+SGLT2]**
- AFib: **BB or Non-DHP CCB**
49
When should Dyslipidemia be used in Secondary Stroke Prevention?
- After **atherosclerotic ischemic** should be given a **High Intensity Statin** [Ator 40-80mg or Rosuv 20-40mg]
- GOAL: **LDL < 70**
- **DO NOT** use statin in **Cardioembolic or Hemorrhagic**
50
What are some other Additional Risk Factors to reduce in Secondary Stroke Prevention?
- Cessation of Illicit Drugs [Cocaine]
- Decrease Alcohol
- Diabetes Control [**A1c < 7**]
- Physical Acitivity
- Dieting
- Weight Loss
- Smoking Cessation
51
When should Antidepressants be started in those that have had a stroke?
- **AFTER STROKE**
- SSRIs [**Sertraline, Escitalopram, Citalopram**]
