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PHRM 864 Module 4 > Stroke > Flashcards

Stroke Flashcards

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1
Q

Stroke is

A

an acute focal injury due to lack of blood/oxygen to the central nervous system causing neurological deficits

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2
Q

Types of stroke

A

ischemic: cardioembolic or atherosclerotic
hemorrhagic

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3
Q

Ischemic stroke

A

an infarction of brain tissue resulting from compromised blood flow
atherosclerotic ischemic stroke (build up of plaque) nad cardioembolic ischemic stroke (embolus, due to Afib)

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4
Q

Hemorrhagic stroke

A

bleeding in the brain due to rupture of a cerebral artery; not getting to other areas of vasculature system

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5
Q

Pathophysiology of atherosclerotic stroke

A

partial or full occlusion from cholesterol plaque buildup –> blood clot blocks artery –> decrease in amount of blood to brain
platelet and lipids are primary targets

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6
Q

Pathophysiology of cardioembolic stroke

A

atrial fibrillation in left atrium

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7
Q

Pathophysiology of hemorrhagic stroke

A

aneurysm in cerebral artery breaks open, causing bleeding around brain; pressure of blood on brain causes brain tissue death

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8
Q

Stroke risk factors

A

non-modifiable: age, family history, females, race, low birth weight, sickle cell disease
modifiable: CV diseases (Afib, valvular diseases), diabetes, hyperlipidemia, HTN, illicit drug/alcohol abuse, obesity/physical inactivity, cigarette smoking

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9
Q

Clinical presentation: FAST

A

face drooping
arm weakness
speech difficulty
time to call 911

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10
Q

Clinical presentation

A

dysphasia (difficulty speaking), facial droop, unilateral/bilateral weakness, ataxia (inability to coordinate muscle movement), vision changes (diplopia), HA (more common with hemorrhagic)

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11
Q

Symptom evaluation

A

timing of sx onset
NIHSS score 0-42 with increased scores meaning worse prognosis

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12
Q

Assessment

A

imaging
labs
vital signs
tests

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13
Q

Assessment: imaging

A

head CT or MRI - look in brain to see if there’s an active bleed or occlusion

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14
Q

Assessment: vital signs

A

blood pressure
oxygen saturation (<90, give O2)

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15
Q

Assessment: labs

A

blood glucose
basic metabolic panel
complete blood count
hematologic markers: INR, aPTT

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16
Q

Assessment: tests

A

ECG (looking for Afib)
echocardiogram
if ischemic stroke with Afib or valvular abnormalities, usually cardioembolic; if ischemic stroke with normal sinus rhythm, usually atherosclerotic

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17
Q

Goals of treatment for acute stroke

A

limit extent of neurologic injury and long-term disability
decrease mortality
prevent future strokes

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18
Q

Gylcemic control

A

hypoglycemia: can cause neurological changes mimicking a stroke; treat with carbs to maintain euglycemia
hyperglycemia: in setting of acute stroke, elevated BG (>180 mg/dL) has resulted in worse morbidity and mortality; treat with SC insulin to maintain BG < 180 mg/dL while inpatient (only use insulin drip if pt in acidosis)

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19
Q

Medication access

A

due to physiologic changes after a stroke, pts must be evaluated for their ability to swallow
if NPO, utilize alternate route: IV, topical, rectal, feeding tube

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20
Q

Acute blood pressure management

A

argument for reducing blood pressure: minimize long-term neurological deficits, decrease risk of cerebral edema and hemorrhagic transformation, prevention of early recurrent stroke
argument against reducing blood pressure: dropping BP too quickly can limit brain perfusion which can worsen ischemia and neurologic fx
BP control after a stroke requires a balance

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21
Q

Acute blood pressure goals

A

check BP q15min x 2hr than q30min x 6hr then q1hr for 16hr
BP goals within first 48 hours: higher than normal BP goals to allow permissive HTN
no tPA: <220/110 mmHg
tPA given: <180/105 mmHg (lower goal b/c tPA risk factor is bleeding –> higher BP, highier risk of hemorrhagic stroke
after first 48hrs, BP goal gradually lowers to outpatient BP goal

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22
Q

Acute HTN treatment options

A

labetalol 10-20mg IV q10-20min (max 300mg)
nicardipine 5mg/hr IV titrated q5min to BP goal (max 15mghr)
sodium nitroprusside 0.5-10 mcg/kg/min IV titrated to BP goal (use if DBP > 140 mmHg)

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23
Q

HTN management after 48hrs

A

if BP still elevated, start PO meds if able to take: resume home antihypertensives, if no home therapy, start new

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24
Q

HTN management summary

A

utilize antihypertensives if above BP goal to minimize risk for hemorrhagic stroke: goal BP < 180/105 mmHg if tPA given, goal BP < 220/110 mmHg if no tPA
after 48hrs if patient hypertensive, gradually reduce to outpatient goal trhough (re)initiation of oral antihypertensives

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25
Acute ischemic stroke management: thrombolytics
tissue plasminogen activator (tPA) - alteplase and tenecteplase activate plasminogen --> converts plasmin --> lyses clot
26
Which type of stroke would you use a thrombolytic?
ischemic: atherosclerotic and cardioembolic
27
Thrombolytics utility
improves functional capabilities after an ischemic stroke (any ischemic stroke - cardioembolic, atherosclerotic) NO impact on mortality, but can improve neurologic fx ONLY in pts meeting eligibility criteria!!
28
tPA eligibility
must meet ALL inclusion and NO exclusion criteria inclusion: diagnosis of ischemic stroke confirmed by imaging, sx onset /= 18yrs exclusion: BP > 185/110 at time of adminsitration, BG < 50 mg/dL, anything that increases risk of bleeding
29
tPA agent - alteplase
0.9mg/kg IV (max 90mg) 10% given as bolus over 1 min: 0.09mg/kg 90% remaining infused over 60 min: 0.81mg/kg
30
tPA agents - tenecteplase
0.25mg/kg IV (max 25mg) all given as IV bolus
31
tPA agents SEs
bleeding (including potentially causing hemorrhagic stroke) - keep BP < 180/105 mmHg to reduce risk of bleeding/hemorrhagic stroke and avoid ALL antiplatelets and anticoagulants for 24hrs after cerebral edema
32
Thrombolytic summary
pt must meet inclusion with NO exclusion criteria dosing - be aware of max dose! if administered, monitor for s/sx of bleeding, maintain BP goal, and avoid anticoagulants/antiplatelets for 24hrs
33
Acute ischemic stroke management - antiplatelets
decrease in activation of P2Y12; COX enzyme inhibition help decrease activation/aggregation of platelets
34
Antiplatelet options for acute ischemic stroke management
aspirin monotherapy aspirin + clopidogrel ticagrelor aspirin + ticagrelor
35
Aspirin
MOA: irreversible inhibitor of COX enzyme, reducing formation of thromboxane A2, thus reducing platelet aggregation for 1st line acute management of ischemic stroke monitor: bleeding, stroke
36
Who gets aspirin for a stroke?
ALL ischemic stroke pts initially, unless contraindicated: includes both embolic and atherosclerotic ischemic strokes contraindications: active bleeding or high bleeding risk >/= 24hrs if tPA administered (immediately if no tPA)
37
Aspirin + clopidogrel
MOA: clopidogrel is a P2Y12 inhibitor which inhibits platelet aggregation through blockade of the ADP receptor combo ONLY in minor strokes (NIHSS
38
Ticagrelor
MOA: P2Y12 inhibitor which inhibits platelet aggregation through blockade of the ADP receptor ONLY in minor strokes (NIHSS
39
Therapeutic anticoagulants
lack of research of therapeutic anticoagulants in the acute management of an ischemic stroke: no improvement in neurological fx or prevention of early recurrent stroke and increased bleeding - use aspirin instead to minimize risk of recurrent stroke acutely
40
What if a pt comes in on an anticoagulant?
d/c anticoagulant and transition to aspirin will NOT use tPA if on anticoagulant if cardioembolic ischemic stroke or other indication for anticoagulant, recommended to start >/= 2-14 days after stroke
41
Acute ischemic stroke summary
evaluate appropriateness of tPA BP and glycemic control help minimize complications post-stroke BP goal differs based on administration of tPA or not antiplatelets recommended in acute management to prevent early recurrent ischemic stroke monitor BP, s/sx of bleeding, stroke
42
Hemorrhagic stroke overview
distinguishing sx: severe HA; usually more present compared to ischemic stroke worse prognosis - increased mortality and worse functional outcomes goal is to prevent re-bleeding/worsening of bleed
43
For a subarachnoid hemorrhage use
nimodipine for vasospasms
44
Acute managment overview
supportive care, glycemic control, reversing causative meds, surgery, antihypertensives, prevention of cerebral vasospasm, anticonvulsants
45
Reversing causative medications
warfarin: IV vitamin K heparin products: protamine DOACs: dagitaran - idarucizumab (praxabind); other DOACs - recombinant coagulation factor Xa (andexxa) antiplatelets: no antidote holding agents, then giving reversals
46
Surgery
craniotomy endoscopic coiling or surgical clipping endoscopic evacuation
47
Antihypertensives - acute hemorrhagic stroke
to prevent acute rebleeding by controlling BP treat if SBP > 180mmHg with IV antihypertensives goal BP in 1st 24 hours < 180/110 mmHg goal BP in hospital after 24 hours < 160/90 mmHg after 48 hours, transtition to outpatient goal BP (<130/80)
48
Prevention of vasospasm in hemorrhagic stroke
after subarachnoid hemorrhagic stroke, pts at risk for cerebral vasospasm which can worsen ischemia - highest risk 4-21 days after subarachnoid hemorrhagic stroke, worsens complications after a stroke nimodipine (DHP CCB) used to minimize complications from cerebral vasospasm after a subarachnoid hemorrhage: 60 mg orally q4h for 21 days after hemorrhage
49
Anticonvulsants
risk of seizure after hemorrhagic stroke prophylactic anticonvulsants NOT recommended only use if pt has a documented seizure history
50
Acute hemorrhagic stroke summary
if stroke due to reversible cause, use antidote or reversal agents if available BP control vital, nimodipine reduces complications from cerebral vasospasm if subarachnoid hemorrhage most management is supportive care
51
Secondary stroke prevention: antiplatelets vs anticoagulants
ischemic stroke pts will need an anticoagulant (more for cardioembolic) or antiplatelet (more for atherosclerotic) to prevent future strokes
52
Secondary stroke prevention: antiplatelets
goal: prevent future strokes through the inhibition of platelet activation/aggregation duration: indefinite until bleeding risk/complications outweigh the benefits of the meds
53
Secondary stroke prevention: aspirin
first line treatment for secondary stroke prevention in atherosclerotic stroke first 2-4wks: 162-325mg PO daily after 2-4wks:
54
Secondary stroke prevention: dipyridamole/aspirin
co-formulated capsule of dipyridamole 200mg/aspirin 25mg BID MOA: dipyridamole inhibits adenosine phosphodiesterase thus preventing platelet aggregation 1st line treatment for secondary stroke prevention in atherosclerotic ischemic stroke use this after transitioning off of high dose aspirin after the initial 2-4wks SE/monitoring: HA, GI bleed
55
Secondary stroke prevention: clopidogrel
2nd line treatment for secondary stroke prevention in nonembolic ischemic stroke (due to atherosclerosis) - use in aspirin intolerant pts, mostly used in combo with aspirin 75mg PO daily SE/monitoring: bleeding
56
Secondary stroke prevention: clopidogrel + aspirin
secondary stroke prevention for atherosclerotic ischemic stroke minor strokes (NIHSS
57
Other antiplatelets in secondary prevention
ticagrelor + aspirin: decreased ischemic strokes, no difference in overall disability and increased bleeding with combo compared to aspirin prasugrel: increased CV events and mortality (DON'T USE) neither is recommended for secondary stroke prevention!
58
Antiplatelets indication in secondary prevention
prevention of secondary strokes in pts with history of atherosclerotic ischemic stroke - recommended in all pts unless high bleeding risk or indications for other anticoagulants/antiplatelets 1st line: aspirin, dipyridamole/aspirin, clopidogrel + aspirin (NIHSS
59
Secondary stroke prevention: anticoagulants
for cardioembolic stroke pts caused by atrial fibrillation, valvular heart disease, or severe heart failure : initiate >/=2-14 days after stroke; immediately after stroke, use aspirin instead of anticoagulant as lower bleeding risk; once starting anticoagulant, d/c aspirin (unless indicated)
60
Secondary stroke prevention in atrial fibrillation: meds
apixaban, dabigatran, edoxaban, rivaroxaban, warfarin if mechanical mitral valve/LV thrombus: warfarin/rivaroxaban
61
Antiplatelet vs anticoagulant summary
used to prevent future occlusion of brain vasculature to minimize risk of future strokes: only use if ischemic!, NOT hemorrhagic
62
Antiplatelet vs anticoagulant: when to use?
cardioembolic (afib, valvular disease, LV thrombus) = anticoagulant atherosclerotic/thrombotic = antiplatelet NOT in combo unless other indications
63
Secondary stroke prevention: hypertension management
long-term goal BP < 130/80 mmHg for all pts with a h/o of stroke per stroke guidelines conflicting results as to best antihypertensive therapy: one trial in stroke showed benefit of ACEis + thiazides; select therapies based on co-morbidities
64
Antihypertensive selection: black
CCB, thiazide
65
Antihypertensive selection: CKD
ACEi, ARB
66
Antihypertensive selection: CAD
BB + ACEi (or ARB)
67
Antihypertensive selection: diabetes
ACEi or ARB
68
Antihypertensive selection: HF
neprilysin inhibitor/ARB, ACEi, or ARB + BB + aldosterone antagonist
69
Antihypertensive selection: atrial fibrillation
BB or non-DHP CCB i.e diltiazem or verapamil
70
Secondary stroke prevention: dyslipidemia
after an atherosclerotic ischemic stroke, all pts should be initiated on a high-intensity statin!: atorvastatin 80 mg daily or rosuvastatin 20-40 mg daily LDL goal < 70 mg/dL: use ezetimibe and PCSK9 inhibitor if unable to reach goal on statin monotherapy DO NOT use a statin if cardioembolic stroke or hemorrhagic stroke
71
Additional risk factor reduction
reduce risk of future strokes through: cessation of illicit drugs (cocaine), reduction in alcohol consumption, diabetes control A1c<7%, physical activity (>/= 150 min/week), diet (mediterranean, low-salt), weight loss, smoking cessation
72
Depression after stroke
occurs 25-50% of pts after an acute stroke worsens recovery and linked to increased mortality
73
Antidepressants
improve neurological functioning after a stroke recommended antidepressants: SSRIs - sertraline, fluoxetine, escitalopram, citalopram AVOID: paroxetine (more anticholinergic SEs), tricyclic antidepressants (anticholinergic SEs, arrhythmias) start low and titrate up; duration unclear
74
Rehabilitation
due to functional changes after a stroke, pts face many challenges including recovering activities of daily living many require therapy at a rehab center to facilitate recovery and reconditioning after a stroke: speech therapy (swallowing, speaking), occupational therapy, physical therapy
75
Ischemic stroke summary
acute management is similar b/w ischemic types (cardioembolic, atherosclerotic) for secondary stroke prevention, differentiate cause of stroke to determine appropriate therapy to minimize risk of future strokes
76
Hemorrhagic stroke summary
mose treatment is supportive and surgical prevent future hemorrhagic strokes wtih: HTN and co-morbidity management, lifestyle modifications, evaluating need for therapies which can increase bleeding risk
77
Stroke Management summary
acute management (inpatient): control BP, consider tPA if ischemic stroke and meets criteria, initiate antiplatelet therapy for ischemic stroke chronic management (outpatient): initiate therapies to reduce risk of future strokes, monitor and manage other risk factors

PHRM 864 Module 4 (7 decks)

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