What is the difference between a hemorrhagic and Ischemic stroke?
Hemorrhagic - Bleeding occurs inside or around brain tissue Ischemic- A clot blocks blood flow to an area of the brain
Strokes cost a lot of money what are some of the reasons why?
Directs costs on hospitalization, skilled nursing care, medications, DME, Home health care. Indirectly- lost of productivity, loss of esteem
Stroke is brain attack damage is not unavoidable Stroke is an emergency Time=?
Reality Strokes are mostly____ Stroke requires ___ treatment Stroke can happen to anyone Stroke recovery is ____
Preventable emergency care recovery is life long
What are the symptoms of strokes?
- Slurred speech, difficulty understanding others - Clumsy or numb legs or arms - One side of body affected - Headache, unusually severe Eyes: loss of sight (one or both) Dizziness
Ischemic stroke is cause by?
- Inadequate blood supply to the brain - Usually due to thrombotic or embolic arterial occlusion - Lack of blood flow causes cell death
Thrombus forms in artery in brain
Clot from outside of the brain, piece breaks loose and travels to the brain
Cell death at the core of an ischemic stroke is?U
Outside of the core is ischemic penumbra which means?
Cells are still salvageable in this area but it is time sensitive, if perfusion is not restored cells will continue to die
WHat are the two classifications of Cerebral Ischemic Events?
Transient Ischemic attacks- perfusion is temporary Cerebral Infarction- 90% of pts have residual deficits
What are the 3 mechanisms of Ischemic Stroke?
L S E
Large vessel disease(Long Artherosclerosis + fast clot) Small vessel dx blood flow blocked by very small arterial vessel Embolism- Clot forms in body somewhere and travels to brain
Small vessel dx is linked to?
Embolism is usually caused by?
A fib- this dislodges clots
Non modifiable risk factors?
I am 55 and Im a dude Im half african american, Hispanic and Asian
Age, gender, Race (AA, Hispanic, Asian-pacific) Genetic factors, low birth weight
Modifiable risk factors?
HTN, A fib, DM, high cholesterol, Carotid stenosis, transient ischemic attacks or previous stroke Lifestyle: EtOH, Drugs, Cig smoking, Obesity, Physical activity, Atherogenic diet
Short term treatment goal of HTN?
reduce brain damage Re-establish perfusion Neuroprotection
Long term treatment
Reduce neurologic injury, Decrease mortality and long term diability, Prevent complications, prevent recurrence by reducing modifiable risks
1) Stabilize ABCs 2) Asses neurologic deficits 3) Get Hx - Single most important piece of information is time that stroke symptoms started 4) Brain imaging - Determine size, location, tissue effects of infarction, bleeding
Treatment of Acute Complications High Bp What drugs are used?
Many patients have elevated BP in first 24-48 hours Not treated unless systolic >220 or DBP >120 Low blood flow to the brain means more brain damage Labetalol, Nicardipine, Nitroprusside
Used nitroprosside if Diastolic is?
Treatment of systemic Thrombolytics
- Restore blood flow to ischemic areas of brain - Early treatment = better outcome - Very high risk of hemorrhage so decision to treat made with caution
Acute stroke treatment two agents recommended?
Tissue plasminogen activator within 4/5 hours of symptom onset ASA within 48 hours of symtom onset
Ateplase is the only FDA approved thrombolytic for acute treatment of ischemic stroke what is it? How does it increase good outcomes? How does it hurt outcomes?
tPA, pts are 30% more likely to have minimal or no disability Intracerebral hemorrhage in 6.4% vs placebo
When should ateplase be given, how is it administers, what should be avoided, what should you monitor?
Within 4.5 hours of symptom onset, IV bolus, Avoid anticoags and antiplat for 24 hours, and monitor Bp response and hemorrhage
Inclusion criteria for tPa Ateplase treatment?
Im 22 my friend my have neuro damage it happened within 4.5 hours
>= 18 Diagnosis of stroke causing meaningful neurologic deficit Clearly defined onset time of less than 4.5 hours before treatmetn
Exclusions for tPa Ateplase treatment?
Evidence of ICH on CT Minor or rapidly improving Sx Predispositon to bleeding, Heparin within the last 48 hours elevated aPTT, current warfarin use, Platelet count less than 100,000 Also Hx of ICH Witnessed seizure at same time as onset of stroke, Symptoms of SAH, GI or urinary tract hemorrhage within 21 days Active internal bleeding Stroke or serious head trauma within 3 months Major surgery or serious trauma within 14 days Recent arterial puncture ar non compressible site or LP within 7 days Acute MI SBP > 185 DBP > 110 at time of treatment
Sooner ateplase is given the greater the benefit. How is efficacy measured?
Improvement in current neurologic deficits Long term neuro status improvement
Adverse effects of tPa
Bleeding - ICH and serious systemic bleeding - Easy bruising - Hematemesis - Black, tarry stool - Hematuria - Bleeding gums -Nosebleeds
ASA treatment If received within ___ ? Continue for ___ weeks assess need for long term dose?
48 hours less likely to suffer recurrent stroke, death and disability 2 weeks 160- 325 mg/d
Efficacy and safety not well established not recommended with current guidelines
Secondary stroke prevention ABCDE!
A- Antiplatelets and anticoag, aspirin, clopidogrel, warfarin B-blood pressure-lowering meds C- Cessation of cigs, cholesterol D- Diet and DM E-Exercise
When is HTN treatment recommended?
>=140/90 Data supports use of diuretics and ACEIs outside of acute stroke period 7 days after
Statin with intensive lipid lowering effects
Use antiplatelets if non-cardioembolic stroke
ASA- 50 - 325 Clopidogrel 75 ASA 25 and ER Dipyridamole 200 mg PO BID
Clopidogrel has the potential for?
A-fib, Valvular Heart Disease, Prosthetic Heart valves
A fib does what to chances of stroke?
Increase chances of stroke
High risk level?
Rivaraxaban a factor Xa inhibitor is indicated for?
reduced risk of stroke in a-fib
Reduce stroke risk in patients with A-fib
Dont use in patients with CrCL > 95 mL/min
a-fib indication 150 mg BID >30 CrCL
Mechanism of clot formation with a prosthetic valve?
Valve is perceived as foreign Change in norma endothelial surface Medium for attachment and proliferation of clotting factors
Anticoag recommendations in pts with fake valves
Warfarin nothing else is recommended Recommendation is based on valve type mechanical or bioprosthetics INR range typically 2.5-3.5
Assesing stroke risk
- Tools are available, helps identify those who could benefit from intervention
Framingham stroke profile?
Gender, age, SBP, DM, Smoking, A-fib, LVH, CVD
Screen for it, every 2 years more often in minority or old
Control BG Control Bp
>= 30 min of moderate intensity Low sodium diet and high fruits and veggies
Can be harmful if other risks are present
ASA is not recommended in?
Patients with low risk
81 mg a day for?
Patients with high risk
Transient Ischemic Attack?
Temporary reduction in perfusion to focal region of brain Short lived Caused by small clot breaking off of smaller one This may be the only warning of impending stroke
Clinical presentation of TIA?
Involves loss of vison, motor deficit, sensory deficit, dysarthria, Lasts for less than 24 hours but usually less than 30 minutes So brief hard to diagnose
TIA are directly proportional to?
Risk of stroke
All pts with TIA should have long term?
Sebarachniod Hemorrhage (SAH) is a type of Hemorragic stroke
Bleeding into spaces between inner and middle layers of meninges Often due to trauma or cerebral aneuysm
ICH Intra cerebral hemorrhage
Bleeding directly into brain parenchyma, often due to chronic uncontrolled HTN
Bleeding under dura, often result of head trauma
Hemorrhagic stroke has 50% mortality at ___ days?
Symptoms of Hemorrhagic stroke?
Sudden, severe headache, N/V, Photophobia, neck pain, Nuchal rigidity
Patho of Hemorrhagic
Related to presence of blood in brain tissue or surrounding spaces Hematoma make continue to grow and enlarge after initial bleeding
Weakened blood vessel walls Trauma, infection, congenital, HTN Blood slowly leaks from vessels or may suddenly rupture Anticoags, thrombolytics, sympathomimetics
Risk factors for ICH?
HTN, Trauma, smokig, EtOH, Cerebral aneurysm
Goals for ICH short term?
No standard pharm treatment, Rapid neurointensive treatment Manage increased intracranial pressure Manage Bp
Prevent complications prevent recurrent bleed