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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


Thrombotic Occlusion?

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?


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


Stroke Diagnosis?

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