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Flashcards in Stroke Deck (52):

Hemorrhagic Stroke: Clinical presentation

*Worst headache of your life* and decreased level of conscientious.

other details,
headache, dizziness, seizures, vomiting, neck rigidity


Hemorrhagic Stroke:
Intracerebral hemorrhage

Secondary Causes

uncontrolledbloodpressure ,antithrombotic or thrombolytic


Hemorrhagic Stroke:
Subarachnoidhemorrhage (SAH)

A. Blood enters cerebrospinal fluid

B. Secondary to trauma, rupture of an intracranialaneurysm ,or rupture of an arteriovenous malformation (AVM)


SAH secondary to aneurysm rupture

Associated with increased incidence of delayed cerebral ischemia (DCI)

-> Occurs between 4 and 21 days after bleed
-->Underlying cause of of DCI is vasospasm of cerebral vaculature

Nimodipine - used to reduce the compilation owing to DCI

60mg PO every 4 hours X 21 days

ADR: Hypotension

Reduce dosing interval to 30mg PO every 2h (same daily dose) or reduce total daily dose 30mg PO every 4th


Nimodipine (Nimotop): Black Box Warning

Do not administer intravenously or parenterally. Will cause Death and Serious ADR.


Secondary Prevention: Non-Cardioembolic TIA/Stroke

Artherothrombotic, lacunar, or cryptogenic

What drugs are available and what dose?

Aspirin 50-325 PO daily --Cheap *best

ASA 25 mg /Dipyridamole ER (Aggrenox) 200mg PO BID*ok

Clopidogrel 75mg PO daily *last


Secondary Prevention: Non-Cardioembolic TIA/Stroke

What's better ASA or ASA/dipyridamole( Aggrenox)?

IR dipyridamole failed to show benefit over ASA
-> due to its short half-life and reduced absorption

Aggrenox: HA in 40% of pts. Titrated the does: take 1 pill at night for 2wks, then BID.


Secondary Prevention: Non-Cardioembolic Stroke/TIA

What about long term, Dual anti-playlet therapy?

Combo of ASA and Clopidegrel--> is not recommneed

BUT** DAPT is indicated if history of ACS/PCI --> look for stent or intracranial stenosis.


Secondary Prevention: Cardioembolic Stroke



C - Congestive HF
A2 - age >75 (2 points)
D - DM
S2 - PMH of Stroke (opts)
V - vascular disease
A - age 65-74
Sc - sex category ( Female)

0= Choose nothing
1= Choose nothing or ASA or anticoagulation
≥2= Anticoagulation

o No treatment = 0
o ASA 81 -325 mg po daily (usually 81 mg)
- Warfarin Goal INR 2-3 --DOC
o Dabigatran 150 mg PO BID
o Rivaroxaban 20 mg PO daily with a mea
o Apixaban 5 mg PO BID
o Edoxaban 60 mg PO Daily


Primary and Secondary Prevention of Stroke


Drugs and Goals?

ACEI + Thiazide or ARB



Primary and Secondary Prevention of Stroke

Lipid Management: SPARCL (ATV 80 vs. PLB)

Drugs, situation, and goals

ATV 40-80 mg daily and ROSVA 20-40 mg daily

Stroke only from artherosclorisis.

Decrease in LDL of at least 50% from baseline


Primary and Secondary Prevention of Stroke

Diabetes mellitus with risk or history of CVD

Secondary: ASA 75-162 mg hx of CVD


Primary: Aspirin tx (75–162 mg/day) in (1) DM with 10-year risk>10%.

(2) Men 50 yrs of age or women 60 yrs of age who have at least one of the following factors:
(family hx of CVD, HTN, smoking, dyslipidemia, or albuminuria).

Goal Ha1C


Primary and Secondary Prevention of Stroke

Antiplatelet Treatment – Primary Prevention

PRIMARY: ASA low dose 81 mg

Men ages 45-79 and Women 55-79

For women the major benefit is stroke prevention

men the primary major benefit is MI prevention


Primary and Secondary Prevention of Stroke:

Obesity/Ethanol Use

Weight management program

Exercise program Healthy diet with increased fruits/ vegetables

Limit alcohol intake

Goal body mass index 18.5- 24.9 kg/m2

≤ 2 drinks (males)
≤ 1 drink (non-pregnant females)


Primary and Secondary Prevention of Stroke:



Nicotine patch/ gum


Nonpharmacologic management`


Acute Ischemic Stroke – Treatment

General Treatment Principles

1. To identify candidates for thrombolytics within 4.5 hours**

2. Close monitoring of patient for change in metal status


General Treatment Interventions for Acute Ischemic Stroke

Fluid management: Dehydration and Hypotension

Hyperglycemia: maintain range of 140-180 mg/dL

Hypoglycemia: (38C

Hypertension : mentioned later

DVT/PE prevention: ""


Pharmacologic Treatment of Acute Stroke

Drug/Amistration/BP/other drug??

(r-tPA) alteplase- (Activase® )

• Half life 3-8 minutes

1.Dose: 0.9mg/kg (maximum 90mg)
2.the first 10% given IV bolus
3.remaining 90% given by continuous infusion over 1 hour.
4. BP


(r-tPA) alteplase- (Activase® )

ADR and Precautions

Bleeding, angioedema (tx with ranitidine, diphenhydramine, methylprednisolon)

Develops headache, acute HTN, N/V has worsening neurological exam,
-->discontinue the infusion and obtain emergent CT scan


(r-tPA) alteplase- (Activase® )


Monitoring Parameters:
BP, Neurologic function, bleeding:
1.q15min X 2hrs
2. Then q30min x 6 hrs
3. Then q60min x 24 hrs
4. qshift


NINDS r-tPA Stroke Study Group study:

Excustion Critieria

4. History of previous intracranial hemorrhage

7. Elevated blood pressure > 185/110

10.Platelet count 1.7 or PT >15 seconds

13.Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays

14.Blood glucose concentration


NINDS r-tPA Stroke Study Group study:

Inclusion Critieria

1. Treatment within 45 minutes
2. age > 18
3. ishemic stroke with measurable neuralgic deficit


NINDS r-tPA Stroke Study Group study: (3 hour window)

Relative excision criteria

1. minor or rapidly improving stroke symptoms
3.MI within 3 months
4. any trauma or surgery within 14 days
5. UTI or GI hemorrhage within 21 days


ECASS Study:

Additional exclusion criteria if within 3-4.5 hours of onset.

! Patient > 80 years
! Those taking oral anticoagulant regardless of their INR
! Baseline NIHSS score > 25
! Those with hx of stroke and diabetes


ECASS Study: Expansion of the Time Window for Tx of Acute Ischemic Stroke with r-tPA

patients to test the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke

AHA/ASA recommends r-tPA to be given to eligible patients who can be treated in the time period of 3-4.5 hours after stroke


NINDS r-tPA Stroke Study Group study:

When inclusion and exclusion of giving rtPA not followed there is increased risk of hemorrhage 15.7 % - 3X rate in other studies

The bottom -Stick with the guidelines for giving r-tPA


Acute Ischemic Stroke: Antiplatelet agents


• 325 mg within 48 hours after stroke onset

Wait 24 hours if tPA was used


Acute Ischemic Stroke: Antiplatelet agents


The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 90 days

If the patient ends up receiving rtPA, then aspirin 325mg or DAPT can be given after 24 hours


Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH

• Has NOT been shown to decrease disability or mortality
• Has NOT been shown to decrease risk of recurrent stroke • # risk for systemic and CNS hemorrhage


Acute Ischemic Stroke: full dose (or treatment dose) anticoagulation with Heparin or LMWH:


Do not use anticoagulation for stroke or A.Fib (UFH/LMWH)

For most patients with a stroke or TIA in the setting of AF, it is reasonable to initiate *ORAL* anticoagulation within 14 days after the onset of neurological symptoms


Acute Ischemic Stroke: antithrombotic tx for prevention of DVT/PE

Low dose UFH/LMWH should be *restricted for 24 hours* after administration of thrombolytic therapy.

low dose has less risk of intracrannial hemorrhage


Blood Pressure Management in Acute Stroke

Used to achieve 185/110 so tPA can be used

if not using tPA:

Use if BP > 220/120


When patient has the following medical conditions:

• Evidence of aortic dissection
• Acute myocardial infarction
• Pulmonary edema
• Hypertensive encephalopathy

Goal: reduce systolic BP by 15% during the 1st 24 hrs after stroke onset


Blood Pressure Management in Acute Stroke

Agents :Indication that patient is eligible for treatment with intravenous rtPA

SBP >185mmHg or DBP>110mmHg

Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat once


Nicardipine infusion (dihyropyridine CCB)
5 mg/h, titrate up by 2.5 mg/h, , maximum dose 15 mg/h; when desired blood
pressure reached.


If BP is not maintained at or below 185/110 mmHg, do NOT administer rtPA


Labetalol ADR

Labetalol: Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension


Nicardipine ADR

Nicardipine: Tachycardia, headache, flushing, local phlebitis


Nitroprusside ADR

Nitroprusside: Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication


Blood Pressure Management in Acute Stroke

Management of blood pressure during and after treatment with rtPA or other acute reperfusion intervention – maintain BP at or below 180/105 mmH

SBP between 180-230 mmHg or
DBP between 105-120 mmHg

Labetalol 10 mg IV followed by an continuous infusion at 2 to 8 mg/min


Nicardipine infusion, 5 mg/h, titrate up to desired effect by
increasing 2.5 mg/h every 5 minutes to maximum of 15 mg/h


Blood Pressure Management in Acute Stroke

Management of blood pressure during and after treatment with rtPA or other acute reperfusion intervention – maintain BP at or below 180/105 mmH

DBP > 140 mmHg or if BP not controlled

*Nitroprusside: 0.5mcg/kg/min titrate Q 5min by 0.25mcg/kg/min to max 10mcg/kg/min


Stroke: Symptoms

Weakness on one side of the body, inability to speak, loss of vision, vertigo, or falling


Ischemic stroke is not usually painful, but patients may complain of headache, and with hemorrhagic stroke, it can be very severe.
! Teach FAST (Face, Arm, Speech, Time)


Tests for Evaluation of Ischemic/hemorrhagic Stroke

CT (  ) of the brain without contrast – most important test to distinguish between hemorrhagic vs. ischemic--Bright White AREA

MRI –high resolution; reveals areas of ischemia earlier Electrocardiogram – A.fib detection

Carotid Doppler (CD) – to detect stenosis/atherosclerosis extracranial

Transcranial Doppler (TCD) – to detect stenosis/atherosclerosis intracranial



Scales for stroke

• National Institutes of Health Stroke Scale (NIHSS)
o Evaluates neurologic impairment on a scale of 1 – 42, with higher scores
indicating severe neurologic impairment. (usually performed at presentation, 24hrs after admission, and again at discharge).

• Modified Rankin Scale (mRS)
o A scoring system for measuring disability; scores of 0-1 indicating no to
minimal disability; scores of 5-6 indicates severe disability or death. (usually performed at presentation, 24hrs after admission, and again at discharge).

• Glasgow Outcome Scale (GOS)
o Measure of functional recovery with 1 indicated death and 5 indicating good


Complications of Acute Ischemic Stroke

Cerebral edema
↑ intracranial pressure (ICP)
Hemorrhagic transformation Seizures

Aspiration Hypoventilation
Myocardial ischemia
Cardiac arrhythmias
Deep vein thrombosis
Pulmonary embolism
Urinary tract infection
Pressure ulcers


Cerebral blood flow (CBF):

Normal CBF

Neurological dysfunction



NormalCBF-50mL/100g braintissue/min-Mean Arterial Pressure 50 to 150mmH

Neurologicaldysfunction-~20mL/100g/min - Ishemia ensues

Infarction- 8-12mL/100g/min--irreversible damage

Penumbra--(~15-20 mL/100g/min; @3-4.5hr): tissue that is ischemic but maintains membrane integrity; potentially salvageable through intervention.


Risk Factors: stroke

Non- Modifiable

Non- Modifiable

Family h/o TIA/ CVA
Low birth weight


Risk Factors: stroke


HTN: Most important modifiable risk factor
Heart disease: A.fib (most important/treatable) & other cardiac diseases
Diabetes mellitus
Obesity/Physical Inactivity
Tobacco use
Postmenopausal Hormone Therapy
Sickle cell disease
Oral contraceptives


Risk Factors: stroke

Potentially Modifiable

Drug & Alcohol abuse

Sleep disordered breathing

h/o migraine with aura


Transient Ischemic Attack (TIA

Transient Ischemic Attack (TIA): Abrupt onset focal neurological deficit that lasts Less than 24 hours usually less than 30min


Stroke, Cerebrovascular Accident (CVA

Two Types

Ischemic stroke and Intracranial hemorrhagic stroke:


Ischemic stroke

87% of all strokes
**atherothrombotic**-->The final result is arterial occasion,DECREASING BLOOD FLOW AND CAUSING ISCHEMIA DISTAL TO THE OCCLUSION



Intracranial hemorrhagic stroke

**ADRs: warfarin, heparin, ASA, clopidogrel, lytics**

cerebral aneurysm
arteriovenous malformation


Stoke and Women: it was meant to be.

E. Gender: Stroke is the third-leading cause of death for women.

• Some of the impact is explained by the fact that women live longer, and thus the
lifetime risk of stroke in those aged 55 to 75 years is higher in women (20%) than
men (17%)

• Female specific risk factors: Oral contraceptive use, Postmenopausal Hormone
therapy, Pregnancy (Preeclampsia / gestational hypertension, gestational

• Risk Factors That Are Stronger or More Prevalent in Women: A.Fib, HTN,

Migraines with aura, HTN, depression, psychosocial stress


southeastern US AND stroke

Stroke Belt